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Performance audit and sunset review, Arizona Medical Board

Performance audit and sunset review, Arizona Medical Board

A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
Performance Audit and Sunset Review
Arizona Medical Board
Performance Audit Division
June • 2011
REPORT NO. 11-04
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to im-prove
the operations of state and local government entities. To this end, she provides financial audits and accounting services to
the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of school
districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Audit Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
Dale Chapman, Director
Dot Reinhard, Manager and Contact Person
Emily Chipman, Team Leader
Mike Devine
Rose Tarbell
Senator Rick Murphy, Chair
Senator Andy Biggs
Senator Olivia Cajero Bedford
Senator Rich Crandall
Senator Kyrsten Sinema
Senator Russell Pearce (ex officio)
Representative Carl Seel, Vice Chair
Representative Eric Meyer
Representative Justin Olson
Representative Bob Robson
Representative Anna Tovar
Representative Andy Tobin (ex officio)
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
MELANIE M. CHESNEY
DEPUTY AUDITOR GENERAL
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
June 23, 2011
Members of the Arizona Legislature
The Honorable Janice K. Brewer, Governor
Douglas D. Lee, M.D., Chair
Arizona Medical Board
Ms. Lisa Wynn, Executive Director
Arizona Medical Board
Transmitted herewith is a report of the Auditor General, A Performance Audit and Sunset
Review of the Arizona Medical Board. This report is in response to a November 3, 2009,
resolution of the Joint Legislative Audit Committee. The performance audit was conducted
as part of the sunset review process prescribed in Arizona Revised Statutes §41-2951 et
seq. I am also transmitting within this report a copy of the Report Highlights for this audit to
provide a quick summary for your convenience.
As outlined in its response, the Arizona Medical Board agrees with all of the findings and
reports that it has implemented or plans to implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on June 24, 2011.
Sincerely,
Debbie Davenport
Auditor General
Attachment
cc: Arizona Medical Board Members
The Board regulates medical doctors
through licensing and by investigating
complaints and taking appropriate
disciplinary or nondisciplinary action. The
Board also uses a private contractor to
administer two integrated programs
established to assist doctors who are
impaired by drug or alcohol abuse, or
who have medical, psychiatric,
2011
June • Report No. 11-04
Arizona Medical Board
Our Conclusion
The Arizona Medical Board
(Board) regulates medical
doctors through licensing
and investigating
complaints against them.
The Board should establish
written guidance for
executive director
complaint dismissals and
take steps to improve
complaint-handling
timeliness. The Board uses
staff doctors and medical
consultants to assist it in
investigating complaints
against doctors. The Board
should improve the staff
doctor/medical consultant
selection process and
ensure that consultants
complete training. The
Board should also develop
guidance on using medical
consultants whose
previous work may have
been inadequate.
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
Board regulates
medical doctors
psychological, or behavioral health
disorders that may impact their ability to
safely practice.
Board lacks guidance for executive
director dismissals—As authorized by
statute, the Board has delegated authority
to the Executive Director to dismiss
complaints. Although the Board generally
sustained the Executive Director’s
calendar year 2010 decisions, it has not
established policies and procedures to
guide the Executive Director’s decision
making, including what factors should be
considered when deciding whether to
dismiss a complaint.
Some complaints not resolved in a
timely manner—We have found that
health regulatory boards should generally
process complaints within 180 days from
the time the complaint is received to when
the board resolves it. However, our
analysis of board data showed that if the
Executive Director did not dismiss a
complaint, it generally took more than 180
days before it was resolved. To ensure
that it processes more complaints within
180 days, the Board needs additional
information that will allow it to determine
its overall timeliness. For example, the
Board has a report that provides
information only about timeliness of
complaint investigations, but it should
develop a report to capture additional
complaint-handling steps, such as the
date its Staff Investigational Review
Committee reviews the complaint before
forwarding the complaint to the Executive
Director for dismissal or to the Board for
review and/or final action. The Board
should use this information to address
factors within its control that cause delays
in the complaint-handling process.
Recommendations:
The Board should:
• Adopt written policies and procedures
its Executive Director can use in decid-ing
whether to dismiss a complaint.
• Develop a report to capture additional
complaint-handling timeliness informa-tion
and use the information to
address timeliness issues.
Board should enhance executive director
complaint dismissal guidance and improve
complaint-handling timeliness
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
June 2011 • Report No. 11-04
A copy of the full report is available at:
www.azauditor.gov
Contact person:
Dot Reinhard (602) 553-0333
According to board management, in addition to
staff investigators who review professional conduct
complaints, the Board has one full-time and three
part-time staff doctors who review quality-of-care
and, in limited cases, professional conduct
complaints. According to board staff, for complaints
where these doctors do not have the time or
needed expertise or have a conflict of interest, the
Board will choose a medical consultant from among
almost 1,500 doctors who have volunteered their
services and meet certain qualifications established
by the Board. A consultant receives $150 to review
a complaint and advise the Board whether the
doctor under investigation deviated from the
standard of care. According to board information,
approximately 380 medical consultants reviewed
about 870 complaints in fiscal year 2010.
Board lacks clear guidance on how to select a
staff doctor or medical consultant—Based on our
review of a sample of complaints, most
assignments were made because the staff doctor’s
or consultant’s expertise was the same as that of
the doctor under investigation. However, in some
cases, the reasons for selecting a staff doctor or
consultant were not documented. Because a
formalized process helps ensure that the Board’s
intentions are carried out, the Board should
establish criteria in policies and procedures for
selecting staff doctors or consultants with the
appropriate expertise to review complaints.
Board should ensure that consultants complete
training—The Board provides its consultants with
training materials that provide guidance on how to
identify the standard of care, how to determine
whether the doctor deviated from the standard, and
what information to include in the report that the
consultant prepares. However, the Board does not
require or verify that consultants complete the
training before reviewing complaints.
Guidance is needed on what to do when a
consultant’s work is inadequate—Sometimes a
consultant is not qualified to review a complaint or a
consultant’s report is inadequate.
For example, in one complaint, the consultant did
not address all of a complainant’s concerns, and in
another complaint, a consultant provided
inconsistent information on whether the doctor
deviated from the standard of care.
Board staff and the Board have opportunities to
review medical consultant reports, and these
reviews have identified concerns. According to
board staff, new consultants can be selected if
concerns are identified. In addition, staff reported
that licensees sometimes raise concerns about a
consultant’s conflict of interest or applying the
appropriate standard of care. If these concerns
have a sound basis, board staff will request that
another consultant review the complaint.
However, when these instances occur, staff have no
guidance on whether or not to use the same
consultant again. Consequently, staff sometimes
give consultants a second chance. This may be
appropriate, such as when a report is late because
of unforeseen circumstances; however, it may not
be appropriate if the consultant failed to recuse
himself/herself because of a conflict of interest. In
addition to lacking guidance, the Board does not
adequately document problems with consultants’
work in its computer system. Without adequate
information in the system, it may not be clear
whether a medical consultant should be used
again.
Recommendations:
The Board should:
• Formalize the staff doctor and medical consul-tant
selection process in policies and proce-dures.
• Require that consultants complete the board
training before reviewing complaints.
• Provide guidance on when consultants should
not be used again and where this information
should be documented.
Board should formalize and enhance staff doctor and
medical consultant processes
Arizona Medical Board
Office of the Auditor General
TABLE OF CONTENTS
page i
Introduction 1
Finding 1: Board should improve staff doctor and medical
consultant selection, medical consultant training,
and problem resolution practices 7
Staff doctors and medical consultants review complaints 7
Qualification and selection practices should be formalized 7
Board should require and ensure medical consultants complete training 9
Board should develop additional guidance for using
medical consultants again after problems develop with their work 10
Recommendations 11
Sunset factor analysis 13
Appendix A: Methodology a-i
Agency Response
Figure
1 Summary of Complaint-Handling Process 3
Table
1 Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2008 through 2011 6
concluded
State of Arizona
page ii
Board responsible for regulating licensed
medical doctors
The Office of the Auditor
General has conducted a
performance audit and
sunset review of the
Arizona Medical Board
(Board) pursuant to a
November 3, 2009,
resolution of the Joint
Legislative Audit
Committee. This audit was
conducted as part of the
sunset review process
prescribed in Arizona
Revised Statutes (A.R.S.)
§41-2951 et seq. This
performance audit and
sunset review of the Board
focused on determining
whether the Board’s
complaint-handling
processes and practices
helped ensure that
complaints were
appropriately investigated,
adjudicated, sanctioned,
and processed in a timely
manner. This report also
includes responses to the
sunset factors specified in
A.R.S. §41-2954.
Board mission
The Board regulates the practice of allopathic medicine in Arizona
through licensure and complaint investigation and resolution related to
medical doctors, or MDs. According to A.R.S. §32-1403(A), “The
primary duty of the board is to protect the public from unlawful,
incompetent, unqualified, impaired or unprofessional practitioners of
allopathic medicine through licensure, regulation and rehabilitation of
the profession in this state.”
Licensing requirements
The Board is responsible for issuing licenses to practice medicine to
qualified applicants, and biennially issuing renewal licenses to qualified
active license holders who
seek renewal. During fiscal
year 2010, the Board issued
1,275 initial licenses and
9,722 renewals. According
to board documentation, as
of February 2011, there were
21,110 actively licensed
doctors in Arizona.1 License
applicants must successfully
pass all three parts of the
United States Medical
Licensing Exam or other
statutorily approved exams
and meet ten statutory
requirements (see textbox
for examples of the
1 According to a board official, this number does not include teaching licenses, educational teaching
permits, training permits, dispensing registrations, locum tenens registrations, or pro bono
registrations. A locum tenens registration authorizes an out-of-state doctor to temporarily assist or
substitute for an Arizona doctor. A pro-bono registration allows doctors who are not licensees to
practice in Arizona for 60 days provided that they meet certain requirements, such as not being the
subject of an unresolved complaint.
page 1
Office of the Auditor General
a
Licensing requirements
According to A.R.S. §32-1422, applicants
for licensure must meet ten basic
requirements, including:
• Graduating from an approved school
of medicine;
• Successfully completing an approved
12-month hospital internship,
residency, or clinical fellowship
program;
• Having the physical and mental
capability to safely engage in the
practice of medicine; and
• Paying all fees required by the Board.
Source: Auditor General staff analysis of A.R.S. §32-
1422.
Scope and Objectives
Introduction
page 2
State of Arizona
requirements).1 License applicants must pay a $500 initial license application fee
and, if the application is approved, a $500 issuance fee, which may be prorated from
date of issuance to date of license renewal.2 Doctors renewing their license must
attest that they have completed required continuing medical education and pay a
$500 renewal fee.3
Complaint-handling process
The Board is also responsible for investigating
and adjudicating complaints against licensed
doctors and taking appropriate disciplinary or
nondisciplinary action. A.R.S. §32-1451 states
that the Board may investigate any evidence
that may show that a doctor is or may be
medically incompetent, is or may be guilty of
unprofessional conduct, or is or may be mentally
or physically unable to safely engage in the
practice of medicine. As outlined in Figure 1
(see page 3), the complaint-handling process
involves several steps, including an investigation
to determine whether it appears that the
allegations in a complaint are supported and a
review of the complaint and investigation
material by board management before being
sent to the Executive Director or Board for
further review and action.
After completing an investigation, the Executive
Director or Board may dismiss the complaint, or
the Board may take several other nondisciplinary
and disciplinary actions (see textbox). According
to board data, the Board received approximately
1,035 complaints during fiscal year 2010 that
were within its jurisdiction. Board data also
1 According to the American Medical Association Web site, some medical students and doctors completed other
national exams prior to the implementation of the United States Medical Licensing Exam in 1994. A.R.S. §32-1426
permits the Board to grant licenses to applicants who completed exams prior to implementation of the United States
Medical License Exam.
2 A.R.S. §32-1436 requires that the Board annually establish by a formal vote nonrefundable license issuance and
renewal fees. Although a review of the Attorney General Handbook found that the Board should establish its fees in
administrative rule, the Board has not done so due to a moratorium on rule making. As a result, the Board’s rules have
not been updated to reflect its changed fees.
3 According to board management, licensees are asked to attest whether or not they have completed required
continuing medical education requirements. However, licensees are required to submit proof of completing the
continuing medical education requirements if selected as part of an audit to determine compliance. Board policy
establishes that 5 percent of licensees will be audited each year.
Board nondisciplinary and disciplinary
options
Nondisciplinary options:
• Require continuing medical education.
• Issue an advisory letter.
Disciplinary options:
• Require continuing medical education.
• Enter into an agreement to restrict or limit
the doctor’s practice or professional
activities or to rehabilitate, retrain, or assess
the doctor.
• Issue a letter of reprimand.
• Issue a decree of censure. A decree of
censure is an official action against the
doctor’s license and may include a
requirement for restitution of fees to a patient
resulting from violations of statutes or rules.
• Impose a civil penalty of not less than
$1,000 or more than $10,000 for each
violation of statute or rule.
• Fix a period and terms of probation.
• Suspend or revoke a license.
Source: Auditor General staff analysis of A.R.S. §32-1451.
page 3
Office of the Auditor General
Source: Auditor General staff analysis of the Board’s complaint-handling process.
Figure 1: Summary of Complaint-Handling Process
Complaint Received
Complaint received and intake
process completed. (See Box A)
Complaint Investigated
Complaint investigation
completed. (See Box B)
Investigation Reviewed
Supervisor reviews complaint
investigation and requests
further investigation as needed.
(See Box C)
SIRC Review and
Recommendation
The Staff Investigational
Review Committee (SIRC)
reviews the complaint and
requests further investigation
as needed.
SIRC recommends one of
three outcomes. SIRC also
notifies the licensee of
nondisciplinary or disciplinary
recommendations.
(See Box D)
Outcome 3:
OAH reviews license revocation
or suspension
recommendations
All cases for which the Board
recommends license revocation
or suspension for longer than 12
months are sent to OAH. The
Board considers OAH’s resulting
recommendation when making its
final decision on complaint
resolution.
Outcome 2:
Board reviews a limited number
of dismissal recommendations
and all recommendations other
than license suspensions for
longer than 12 months or
revocations
The Board reviews and approves,
rejects, or modifies SIRC
recommendations and consent
agreements, or may hold formal
interviews if chosen by the
licensee. At this point, the Board
may request additional
investigation, dismiss the
complaint, take nondisciplinary or
disciplinary action, or refer the
case to OAH.
Outcome 1:
Executive Director reviews
majority of dismissal
recommendations
The Executive Director reviews
complaint investigation materials,
including the investigation report,
to determine whether or not to
dismiss the complaint. Licensees
and complainants are notified of
the dismissal decision.
Complainants may request that the
Board review the Executive
Director’s dismissal decisions.
Box B: Complaint Investigation
1. Staff investigator reviews professional conduct evidence. Medical
consultant or on-staff doctor is selected to review quality-of-care
evidence. (For more information about consultants, see Finding 1,
pages 7 through 12.)
2. Staff/consultant writes report concluding on whether the
investigation indicates violations of law or deviations from the
standard of care.
Box C: Investigation Review
The Chief Medical Consultant reviews quality-of-care complaints,
and the Investigations Manager reviews professional conduct
complaints for investigation adequacy and completeness.
These reviewers may:
1. Recommend Executive Director dismissal, or
2. Forward the complaint to SIRC.
Box D: Sanction Options for Licensees
For disciplinary recommendations other than license revocations or
suspensions longer than 12 months, the licensee is notified that
he/she may opt to sign a consent agreement, participate in a
formal interview with the Board, or request that the complaint be
heard by the Office of Administrative Hearings (OAH).
Box A: Complaint Intake Process
Staff review a complaint to determine if it falls within the Board’s
jurisdiction and refer the complaint to a staff investigator. The
investigator assigns a priority based on the seriousness of
allegations; assesses whether the complaint is about quality-of-care
or professional conduct; contacts the complainant to confirm
allegations; notifies doctor(s) named in complaint; and requests
relevant investigation information, such as medical records and
subsequent treating doctor records.
page 4
State of Arizona
shows that the Board investigated and took action on 954 complaints. The Executive
Director dismissed 650 of the 954 complaints, while the Board dismissed 19 of these
complaints.1 In addition, the Board issued 113 advisory letters; 12 orders for
nondisciplinary continuing medical education; 44 disciplinary actions including
letters of reprimand, decrees of censure, probation, or a combination of these
options; and forwarded 1 complaint to formal hearing with the Office of Administrative
Hearings.2 Although the Board did not revoke or suspend a license, 8 licensees
surrendered their licenses.3
Monitored Aftercare and Physician Health Programs
As authorized by statute, the Board has established confidential programs to assist
doctors who are impaired by alcohol or drug abuse, called the Monitored Aftercare
Program, or who have medical, psychiatric, psychological, or behavioral health
disorders that may impact their ability to safely practice medicine or perform
healthcare tasks, called the Physician Health Program. The Board established the
Monitored Aftercare Program in 1987 and the Physician Health Program in 2004, and
integrated the two programs in 2010. The Board uses a private contractor to
administer the integrated programs. According to board staff, there are usually
around 100 licensees enrolled and participating in the integrated programs, and as
of April 15, 2011, 99 licensees were enrolled in the programs. Board management
reported that the integrated programs are paid for by the licensees in the programs.
Board’s role in monitoring medical marijuana
In November 2010, Arizona voters passed the Arizona Medical Marijuana Act. This
citizen initiative—Proposition 203—required the Arizona Department of Health
Services (Department) to create a medical marijuana program within 120 days from
the official election results. According to board management, the program will not
affect its licensing of qualified doctors, but it will affect complaint handling because
the Department will send information to the Board about licensees who are not
following the medical marijuana program rules. Board management reported that
1 A.R.S. §32-1405(C)(21) allows the Board to authorize its Executive Director to dismiss complaints that are without merit.
2 The Board may issue an advisory letter if there is insufficient evidence to support disciplinary action, but continuation of
the licensees’ activities could result in further board action; if the violation is a minor or technical violation that is not of
sufficient merit to warrant disciplinary action; or if the licensee has demonstrated substantial compliance through
rehabilitation or remediation that mitigates the need for disciplinary action.
3 The Board took other action on 107 complaints, such as limiting a licensee’s practice or requiring licensee evaluations
during the investigation of a complaint, and administratively closing complaints. Board management reported that the
Board administratively closes complaints when there is insufficient evidence to support that a violation occurred, but
the allegations are serious enough that the Board would need to reopen the complaint if additional information was
later provided.
page 5
Office of the Auditor General
they have worked closely with the Department on the new rules for the program.
Although board management reported that they anticipate some increase in the
number of complaints referred to the Board for investigation, the Board should have
the resources to handle a moderate workload increase. However, board management
reported possible challenges in obtaining medical consultants to review complaints
related to standard of care because medical marijuana is an emerging practice.
Organization and staffing
As prescribed in A.R.S. §32-1402(A), the Board consists of 12 governor-appointed
members, including 8 who are actively practicing medicine and 4 who represent the
public. One of the four public members is required to be a licensed practical or
professional nurse. Board members serve 5-year terms. The Board is required to
meet at least quarterly, but in practice it convenes every other month to hear
information from the public, obtain updates from its Executive Director and legal
advisor, and take action on complaints. The Board was appropriated 58.5 full-time
equivalent (FTE) staff for fiscal year 2011. However, as of April 2011, it was assisted
in its duties by 35.5 FTE staff, including an Executive Director, Deputy Executive
Director, complaint investigators, licensing staff, and other support staff.
Budget
The Board does not receive any State General Fund monies. Rather, the Board’s
revenue mainly comes from license application and renewal fees. The Board is also
required to remit 10 percent of all its revenues to the State General Fund. As shown
in Table 1 (see page 6), during fiscal year 2010, the Board received approximately
$6.7 million in revenues and remitted approximately $675,000 to the State General
Fund. The Board’s expenditures have declined from approximately $5.9 million in
fiscal year 2008 to less than $5 million in fiscal year 2010. The Board estimates its
expenditures will total a little more than $5 million in fiscal year 2011. The Board
spends nearly two-thirds of its monies for personnel costs, including employee-related
costs. Table 1 also shows the Board was required to transfer approximately
$1.4 million of its available resources to the State General Fund during fiscal year
2008. Smaller transfers were also required in fiscal years 2009 through 2011 (see
Table 1, footnote 3). The transfers significantly decreased the Board’s fund balance;
however, through increased revenues and expenditure reductions, the Board’s fund
balance at the end of fiscal year 2010 has nearly reached its pre-transfers level. The
Board estimates that it will have an ending fund balance of nearly $2.9 million in fiscal
year 2011.
page 6
State of Arizona
Table 1: Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2008 through 2011
1 Amount is net of approximately $12,800, $32,700, $81,600, and $100,900 for fiscal years 2008, 2009, 2010, and 2011,
respectively, for convenience fees the Board collected for online and credit card payments.
2 As required by A.R.S. §32-1406, the Board remits to the State General Fund 10 percent of all revenues.
3 Amount consists of transfers to the State General Fund in accordance with Laws 2008, Ch. 53, §2 and Ch. 285, §46 and Laws
2010, 7th S.S., Ch. 1, §148.
Source: Auditor General staff analysis of the Arizona Financial Information System (AFIS) Accounting Event Transaction File for fiscal
years 2008 through 2010; the AFIS Management Information System Status of General Ledger-Trial Balance screen for fiscal
years 2009 and 2010; and board-provided information for fiscal year 2011 as of May 12, 2011.
2008 2009 2010 2011
(Actual) (Actual) (Actual) (Estimate)
Revenues:
Licenses and fees $ 6,211,795 $ 6,504,774 $ 6,467,923 $ 6,599,400
Fines, forfeits, and penalties 154,399 145,332 144,886 129,400
Charges for goods and services 61,300 47,153 50,232 50,500
Other 14,909 20,793 43,675 3,800
Gross revenues 6,442,403 6,718,052 6,706,716 6,783,100
Net credit card and on-line transaction fees 1 (46,067) (56,418) (22,327) (4,600)
Remittances to the State General Fund 2 (649,072) (663,969) (675,039) (677,500)
Net revenues 5,747,264 5,997,665 6,009,350 6,101,000
Expenditures and transfers:
Personal services and related benefits 3,789,988 3,547,357 3,250,324 3,200,000
Professional and outside services 1,119,061 1,028,717 629,545 700,000
Travel 31,216 35,121 35,870 35,000
Food 4,816 3,124 1,792 1,000
Other operating 685,194 798,996 851,715 800,000
Equipment 287,859 114,420 164,386 321,900
Total expenditures 5,918,134 5,527,735 4,933,632 5,057,900
Transfers to the State General Fund 3 1,401,800 52,100 4,700 122,100
Transfers to Office of Administrative Hearings 34,531 24,432 8,317 20,000
Total expenditures and transfers 7,354,465 5,604,267 4,946,649 5,200,000
Net change in fund balance (1,607,201) 393,398 1,062,701 901,000
Fund balance, beginning of year 2,109,482 502,281 895,679 1,958,380
Fund balance, end of year $ 502,281 $ 895,679 $ 1,958,380 $ 2,859,380
Board should improve staff doctor and
medical consultant selection, medical
consultant training, and problem resolution
practices
The Arizona Medical Board
(Board) should take several
steps to strengthen its
practices for using staff
doctors and medical
consultants to review
complaints against
licensees. The Board uses
both staff doctors and
medical consultants—
licensed doctors who have
volunteered their services—
to review complaints.
However, auditors found
that board staff were
inconsistent in their
explanation and application
of board practices for
selecting staff doctors and
medical consultants. One
underlying reason appears
to be that many of these
practices are not formally
reflected in board policies
and procedures, and in
some cases, the practices
themselves need to be
enhanced. Issues needing
further attention include
criteria for selecting staff
doctors and medical
consultants, requirements
for ensuring that medical
consultants review training
materials provided to them,
and guidance for using
medical consultants again
if limitations in their work
result in the need to obtain
a review from a different
medical consultant.
Staff doctors and medical consultants review
complaints
In addition to staff investigators who review professional conduct complaints,
the Board uses both staff doctors and medical consultants to review
quality-of-care complaints and, on a more limited basis, professional
conduct complaints. According to board management, the Board has one
full-time staff doctor and three part-time staff doctors who review
complaints. The Board’s staff doctors are specialized in cardiology, internal
medicine, obstetrics and gynecology, anesthesiology, and pain
management. Board management reported that if the Board’s staff doctors
do not have the expertise or time needed to review a complaint or have a
conflict of interest with the licensee, a medical consultant will be chosen to
review the complaint.
Based on information provided by the Board, almost 1,500 Arizona-licensed
doctors have volunteered their services to the Board, but must
meet certain qualifications in order to be selected as a medical consultant
(see textbox, page 8). The Board pays medical consultants $150 for each
complaint they investigate. The Board requires medical consultants to
provide an opinion on whether or not a licensee deviated from the standard
of care within 4 weeks of sending the consultant information about how to
access investigative information. This opinion is based on a review of
investigative materials provided by board staff. According to information
provided by board management, the Board used approximately 380
medical consultants to review approximately 870 complaints during fiscal
year 2010.
Qualification and selection practices should be
formalized
The Board has not established clear guidance regarding the process for
assigning complaints to appropriate and qualified staff doctors or medical
page 7
Office of the Auditor General
FINDING 1
page 8
State of Arizona
consultants. When assigning a complaint to a staff doctor or medical consultant, staff
must first determine what specialty is needed for review of a complaint in order to
select a qualified staff doctor or consultant. However, when asked to describe how
they determine what type of specialty is needed, board staff provided different—and
somewhat conflicting—explanations. The absence of a clear and consistent
explanation was also borne out in the sample of complaints that auditors reviewed.
Specifically, staff doctors or medical consultants reviewed 15 of the 22 complaints in
a sample of complaints resolved between August 2009 and February 2011.1 For 12
of these 15 complaints, the staff doctor or medical consultant’s specialty matched
that of the licensee against whom the complaint had been filed. In the remaining 3
complaints, however, the specialty differed from the licensee’s, and the reasons for
choosing someone with a different specialty were not always apparent from the
complaint file. There may be appropriate reasons—such as the particular nature of
the complaint—for selecting a staff doctor or medical consultant with a different
specialty, but the reasons for these selections were not documented. According to
management, the staff doctor or medical consultants in these 3 complaints were
selected based on the particular nature of the complaint or for convenience.2
Clarifying the steps to be followed for selecting a staff doctor or medical consultant
and establishing them in written policies and procedures is important. Established
internal control standards indicate that policies and procedures help ensure that
1 See Appendix A, page a-i, for additional information about the sample of complaints auditors reviewed.
2 For the complaint in which the selection was based on convenience, board management reported that they had only
one on-staff doctor at its office at the time an investigative interview was held with a licensee and that they were
assigned the complaint because they had attended the interview and identified medical documents needed to
investigate the complaint. However, their specialty did not match that of the licensee or the nature of the complaint.
Board staff provided
different and somewhat
conflicting explanations
of how they select a staff
doctor or medical
consultant to review a
complaint.
Medical consultant qualifications and selection practices
Qualifications
• Possess an active Arizona medical license1
• Have no prior or pending board disciplinary action
• Have no real or potential conflict of interest
Selection practices
• Board staff investigators review the complaint to identify the specialty
needed
• A board staff member queries the Board’s database for a qualified
outside medical consultant
1 According to board management, the Board may use an out-of-state medical consultant if there
are so few people practicing within the State that any of them would have a conflict of interest in
reviewing another licensee’s complaint.
Source: Auditor General staff interview with board staff, and analysis of board Web site information
posted at http://www.azmd.gov/Files/OMC/OMC-Orientation/OMC-Orientation_files/frame.
htm
page 9
Office of the Auditor General
directives are carried out.1 Such policies and procedures can help ensure consistent
and appropriate staff doctor or medical consultant selection practices by clarifying
the factors that should be considered when determining what type of specialty is
needed. Therefore, the Board should formalize its staff doctor and medical consultant
selection practices in written policies and procedures, including how board staff
should consider the nature of the complaint and licensees’ practice specialties in
determining the selection of staff doctors or medical consultants. In addition,
although the Board has established medical consultant qualifications, complaint
review time frames, and requirements for medical consultant reports, these practices
have not been formalized in policies and procedures. Therefore, the Board should
establish and implement medical consultant qualifications, medical consultant
complaint review time frames, and report requirements in formal policies and
procedures.
Board should require and ensure medical consultants
complete training
The Board provides its medical consultants with training materials, but it should
ensure that consultants review these materials and verify they have done so. Once a
qualified medical consultant is identified, board staff provide the consultant a link to
training information located on its Web site. The training includes guidance on how
to identify the standard of care and determine whether or not a deviation has
occurred, what information should be included in the report that the consultant
prepares, examples of appropriate reports, and when the consultant should recuse
him/herself from reviewing the complaint. Reviewing this information can help ensure
that consultants conduct a thorough review of all complaint investigative material,
reach appropriate conclusions, and complete an appropriate and adequate
investigative report. However, the Board neither requires consultants to read these
materials nor has a process in place to determine whether they have done so. As a
result, it has no assurance that consultants understand the medical complaint review
requirements. Due to the importance of the training information provided, the Board
should establish and implement a process for requiring and ensuring that its medical
consultants complete the training before reviewing complaints, such as requesting
the consultants’ confirmation that they reviewed the training materials.
1 United States General Accounting Office. (1999). Standards for internal control in the federal government [GAO/AIMD-
00-21.3.1]. Washington, DC: Author.
Reviewing medical
consultant training can
help medical consultants
reach appropriate
conclusions.
page 10
State of Arizona
Board should develop additional guidance for using
medical consultants again after problems develop with
their work
If problems develop with a medical consultant’s work, the Board takes various
actions such as requesting that a different consultant review the complaint, but it has
not developed sufficient policies to consistently determine whether and how the
consultant can be used again. Board policies or practices allow staff, licensees, or
the Board to identify problems with medical consultants’ work. For example:
• Board policy indicates that the Board’s Chief Medical Consultant and its Staff
Investigational Review Committee review all medical consultant reports for
completeness and adequacy, and the three board members auditors interviewed
reported that it is their practice to also review medical consultant reports. These
reviews have identified medical consultant problems, including inadequate
consultant reports and unqualified consultants. Board staff reported that the
Board and its staff can obtain a new medical consultant review when it identifies
these problems. The sample of complaints reviewed by the auditors contained
two such examples where the Board or its staff identified consultant problems.1
In one complaint, the medical consultant did not address all of the concerns
identified by the complainant, and in the other complaint, the consultant
provided inconsistent information on whether the licensee deviated from the
standard of care. For both complaints, the Board or its staff requested that a
second medical consultant review the complaint.
• Licensees have an opportunity to identify concerns with medical consultants
when reviewing consultant reports. Specifically, according to board policy,
licensees are offered an opportunity to review the medical consultant report if
the consultant determines that there was a deviation from the standard of care.
In response to their review of the medical consultant report, licensees are
permitted to provide any new information about the complaint that they feel the
Board should consider. According to board management, licensees will
sometimes mention concerns about potential conflicts of interest or whether the
consultant applied an inappropriate standard of care. Management reported
that they will request a new consultant review of the complaint if it appears that
the licensee’s concerns about the consultant are sound.
Despite these policies and practices, when a review by licensees, the Board, or its
staff establishes that problems exist with a medical consultant’s work, staff do not
have guidance on how to decide whether or not to use the consultant again to review
other complaints. Board staff responsible for maintaining the Board’s list of volunteer
1 Auditors’ review of whether problems were identified with the medical consultant’s review of a complaint was limited to
6 of the 15 complaints in which a medical consultant had been involved. In the remaining complaints, the complaint
was reviewed by a staff doctor or auditors limited their review to assessing the consultant’s qualifications. See Appendix
A, page a-i, for further discussion.
Board member and staff
reviews of medical
consultant reports have
identified problems,
including inadequate
reports.
page 11
Office of the Auditor General
medical consultants reported generally making this determination without guidance,
and sometimes giving consultants a second chance before determining not to use
them again. This second-chance approach may be appropriate in some
circumstances, but not in others. For example, if the consultant was late in submitting
his/her report due to unforeseen circumstances, the Board may still be able to use
this consultant on a subsequent complaint. However, the Board may not want to use
a medical consultant who failed to appropriately recuse him/herself when a conflict
of interest existed. To ensure appropriate medical consultant selection, the Board
should establish and implement written policies and procedures that provide
guidance on when consultants should not be used again, or should be used only for
certain types of complaints.
Additionally, the Board does not adequately document problems identified with
medical consultants and decisions made on whether or not to use consultants again.
Specifically, the Board has not established policies and procedures on the steps to
be taken in documenting such problems, and board staff reported inputting limited
information about consultant-use decisions into the Board’s computer system.
Without adequate information in the system, it may not be clear whether a medical
consultant should be used again. For the two complaints in the auditors’ sample
where the Board or its staff decided to obtain a second consultant’s review, the
entries in the computer system’s field that staff review for information about concerns
with medical consultants did not contain information about these concerns.1
Although staff indicated that problems with consultants may be located in meeting
minutes or in other parts of the computer system, the board staff responsible for
maintaining the Board’s list of volunteer consultants does not consistently review
these other sources of information. Therefore, the Board should establish and
implement policies and procedures on how and where medical consultant problems
and decisions on their continuing use should be documented.
Recommendations:
1.1 The Board should formalize its staff doctor and medical consultant selection
practices in written policies and procedures, including how board staff should
consider the nature of the complaint and licensees’ practice specialties in
determining the selection of consultants.
1.2 The Board should establish and implement policies and procedures regarding
medical consultant qualifications, and complaint review time frames and
requirements.
1 In board meeting minutes, auditors identified three other complaints in which concerns had surfaced about a
consultant’s work. As with the two complaints in the sample, the information in the computer system did not contain
information about these concerns.
The Board does not
adequately document
consultant problems.
page 12
State of Arizona
1.3 The Board should establish and implement a process for requiring and
ensuring that its medical consultants complete board-provided training before
they review complaints. One way to do this would be to request confirmation
from the consultants that they had reviewed the training materials.
1.4 The Board should establish and implement written policies and procedures
that provide guidance on when medical consultants should not be used or
should be used only for certain types of complaints.
1.5 The Board should establish and implement policies and procedures on how
and where problems with specific medical consultants’ work and decisions
regarding the continuing use of these consultants should be documented.
Sunset factor analysis
According to Arizona
Revised Statutes (A.R.S.)
§41-2954, the Legislature
should consider several
factors in determining
whether the Arizona
Medical Board (Board)
should be continued or
terminated. Auditors’
analysis showed strong
performance by the Board
with regard to many of
these factors, but it also
showed a need to
strengthen procedures in
four areas, as follows:
• Formalizing policies for
determining when the
Executive Director can
dismiss a complaint (see
Sunset Factor 2, pages
14 through 15);
• Establishing complaint-monitoring
procedures
that encompass the
entire complaint
process, not just the
limited portion
addressed under current
procedures, to help
improve the timely
processing of
complaints (see Sunset
Factor 2, pages 16
through 17);
• Tightening controls over
sensitive information in
computer systems (see
Sunset Factor 2, page
17); and
• Ensuring it obtains
additional licensee
public information and
provides it on the Web
site as required by
statute (see Sunset
Factor 3, page 18).
1. The objective and purpose in establishing the Board.
The Board regulates the practice of allopathic medicine in Arizona
through licensure and complaint investigation and resolution related
to medical doctors, or MDs. According to A.R.S. §32-1403(A), “The
primary duty of the board is to protect the public from unlawful,
incompetent, unqualified, impaired or unprofessional practitioners of
allopathic medicine through licensure, regulation and rehabilitation of
the profession in this state.”
To accomplish this mission, the Board issues licenses to practice
medicine to qualified applicants, investigates and adjudicates
complaints against licensed doctors, takes disciplinary or
nondisciplinary action as appropriate, and provides information to the
public about licensees through various avenues, including its Web site
and over the phone.
2. The effectiveness with which the Board has met its objective and
purpose and the efficiency with which it has operated.
The Board has effectively met several of its prescribed purposes and
objectives, but needs improvement in some other areas. Some
examples in which the Board is effectively performing include:
• Licensing processes meet requirements—Statute requires
that specific information be included on an application form
provided to the Board, including whether any disciplinary action
has ever been taken against the applicant by another licensing
board, and medical college certification and postgraduate
training. Auditors reviewed the Board’s application form and
found it complies with statute. In addition, the Board processed
the initial license applications issued in fiscal year 2010 within the
120-day overall time frame required by administrative code.
According to the Board’s Administrative Rule R4-16-206, the
Board must conduct an administrative review of a license
application within 120 days of receipt to verify that the application
is complete. Auditors reviewed licensing data for the 1,275
license applications issued in fiscal year 2010 and found that all
but 3 licenses were processed within the 120-day time frame.1
1 For the three applications that the Board did not process within the 120-day time frame, two involved
deficient applications and one applicant was sent for investigation.
page 13
Office of the Auditor General
Sunset Factors
page 14
State of Arizona
Further, according to an April 2011 board report, the Board issued licenses
in January and February 2011 within an average of 37 and 21 days,
respectively.
• Board has established processes to help ensure complaint
investigations are complete and adequate—Board policy requires
several steps during the investigative process, including informing the
licensee of the complaint and requesting his or her response. In addition,
policy indicates that an investigative or medical consultant report
documenting the investigation’s outcome will be developed for each
complaint. In February 2011, the Board revised its investigative policy to
specify that its investigative manager must ensure that investigations are
adequate and complete. Finally, to further ensure the appropriateness and
adequacy of complaint investigation, board staff receive investigative
training.1
Auditors’ reviewed a sample of 17 complaints and found that the Board
followed the investigative steps outlined in its policies and procedures for
each of these complaints. For example, board staff notified both the
complainant and licensee of the receipt of the complaint, and conducted
necessary supervisory reviews for the completeness and adequacy of the
investigation. In addition, auditors reviewed board meeting minutes from
calendar year 2010 containing more than 300 complaints and identified
only 4 complaints where the Board requested additional investigation.
The Board has some sound practices in complaint handling and information
technology, but it can improve the effectiveness of these practices by making
various changes. Specifically:
• Executive Director complaint dismissals appear appropriate, but
additional guidance should be established in policy—A.R.S. §32-
1405(C)(21) permits the Executive Director, if delegated by the Board, to
dismiss complaints that are without merit, and A.R.S. §32-1405(E)
establishes that complainants can request the Board to review the
Executive Director’s decision to dismiss a complaint.2 The Board has
established various practices to help guide these dismissals. Specifically,
board policy requires that the Board’s investigations manager or chief
medical consultant review investigations to check for adequacy and
completeness of the investigation, and indicates that complaints with no
1 Staff attend Council on Licensure Enforcement and Regulation basic and advanced training. In addition, three of the
six staff investigators have taken the first part of a three-part training providing subject-specific education and training
for state medical board investigators, provided by Administrators in Medicine and the Federation of State Medical
Boards.
2 For executive director dismissal reviews, board members are provided with the initial complaint, all complaint
investigation materials, and any subsequent information submitted or obtained as part of or resulting from the
complainant’s request for board review. In addition, the licensee and complainant are permitted to address the Board
at the Board meeting during the Board’s Call to the Public and/or submit a written response for the Board’s
consideration.
page 15
Office of the Auditor General
violations will be submitted to the Executive Director for dismissal. Auditors
reviewed a judgmental sample of five executive director dismissals that the
Board reviewed in February 2011 and found that the investigative reports
provided to the Executive Director indicated there were no violations. In
addition, auditors’ review of meeting minutes from calendar year 2010
identified that the Board generally sustained the Executive Director’s
decisions. Specifically, the Board sustained 65 of the 68 decisions it
reviewed.1
Although the Board has established good practices for executive director
dismissal decisions, it lacks documented policy and procedures outlining
the steps its Executive Director should take when deciding whether to
dismiss a complaint. This was similarly discussed in the Auditor General’s
2004 performance audit (see Report No. 04-L1). Specifically, that audit
recommended that the Board implement policies to guide decision-making
during the complaint review process, including what factors
reviewers should consider when deciding whether to dismiss a complaint.
The Board has established policies and procedures for its complaint
reviewers, including its investigations manager, chief medical consultant,
and its Staff Investigational Review Committee, when recommending the
Executive Director dismiss a complaint or reviewing investigative staff’s
recommendations for the Executive Director’s dismissals. However, the
Board has not established policies and procedures guiding the Executive
Director’s decision-making process, such as what steps to take if there is
a disagreement with staff’s recommendation. Internal control standards
indicate that policies and procedures help ensure that directives are carried
out.2 Therefore, the Board should develop and implement a written policy
and procedures for the Executive Director to use in deciding whether to
dismiss a complaint, including what factors should be considered when
deciding whether a complaint should be dismissed and what to do when
disagreeing with a staff recommendation for dismissal.
• Board should enhance its medical consultant practices—The Board
should take several steps to strengthen its practices for using medical
consultants and staff doctors to review complaints. The Board uses both
staff doctors and medical consultants—licensed doctors who have
volunteered their services—to review complaints. However, auditors found
that board staff were inconsistent in explaining and applying board
practices for selecting staff doctors and medical consultants. One
underlying reason appears to be that many of these practices are not
formally reflected in board policies and procedures, and in some cases, the
practices themselves need to be enhanced. Issues needing further
1 The Board requested additional investigation for two complaints and later dismissed those complaints after additional
investigation was completed and the Board again reviewed the complaints. The Board issued an advisory letter for the
third complaint.
2 United States General Accounting Office (1999). Standards for internal control in the federal government [GAO/AIMD-
00-21.3.1]. Washington, DC: Author.
page 16
State of Arizona
attention include establishing guidance for selecting staff doctors and
medical consultants, requirements for ensuring that consultants review
training materials provided to them, and guidance for using consultants
again if limitations in their work result in the need to obtain a review from a
different consultant (see Finding 1, pages 7 through 12).
• Changes needed to address complaint-handling timeliness—The
Board should take various steps to ensure that it is processing complaints
in a timely manner. The Office of the Auditor General has found that Arizona
health regulatory boards should generally process complaints within 180
days. Auditors’ analysis showed that if the Executive Director does not
dismiss a complaint, it will likely take more than 180 days before it is
resolved (see textbox).
To ensure that it processes more complaints in a timely
manner, the Board needs additional information that will
allow it to determine not only overall timeliness, but also
the timeliness of key steps in the complaint-handling
process. The Board has a report that provides information
about investigation timeliness for each complaint, but the
report does not track other steps in the process, including
the final board action date or the date the Staff
Investigational Review Committee (SIRC) reviews the
complaint before forwarding the complaint to the
Executive Director for dismissal or to the Board for review
and/or final action. In addition, the report does not
include information on each complaint’s priority level.1
Board management reported that they thought the 180-
day standard applied only to the investigative phase.
However, because this standard applies to the entire
complaint-handling process, the Board should develop a
report to capture additional complaint-handling timeliness
information to help identify and address factors in the
process that may impact timeliness. Also, since it is important to handle
serious complaints in a timely manner to protect public safety, the Board
should include the priority level in its report so that it can assess whether
complaints are processed within required time frames according to
assigned priority.2 The Board may also need to modify its computer system
to include additional date fields. For example, the Board may need an
additional field to document the date the SIRC completes its complaint
review. Once the Board has developed a report, it should use this
1 Board policy requires staff investigators to assign complaint priority levels based on the allegations’ severity. Policy also
establishes time frames for completing investigations depending on the priority level.
2 Board management has a report that tracks complaint investigation timeliness according to severity level to ensure
timely investigations, but does not track the remaining parts of the complaint-handling process according to severity
level.
Complaint-Handling Timeliness1
Fiscal Year 2010
Executive director dismissals—650 complaints
• 91% processed within 180 days
• 9% processed within 181 days to 512 days
Board actions—197 complaints
• 24% processed within 180 days
• 26% processed within 181 days to 224 days
• 25% processed within 225 days to 279 days
• 24% processed within 280 to 617 days
1 This analysis does not include the 107 complaints where the
Board took other action, such as limiting a licensee's practice
during the investigation of a complaint (see footnote 3, page 4,
for additional information).
Source: Auditor General staff analysis of the Board’s complaint
data for 847 complaints investigated and resolved during
fiscal year 2010.
page 17
Office of the Auditor General
information to address factors within its control that cause delays in the
complaint-handling process.
• Board needs to improve two IT processes—Although the Board has
addressed information security weaknesses, it should improve its
information technology processes in two areas. According to board
management, the Board’s Web site was compromised in 2008. In
response, the Board obtained an external information technology security
assessment and addressed identified weaknesses. However, to ensure
that only appropriate individuals have access to confidential information,
the Board should follow a standard developed by the state Government
Information Technology Agency (GITA) that calls for classifying data and
developing a plan to secure data based on its classification. For example,
the Board receives patient records during complaint investigations and
licensee social security numbers on license application forms. Due to the
sensitive nature of this information, it is important that only those needing
the information to perform their job functions have access to it. The GITA
standard is intended to ensure that such data is protected within IT
systems.
In addition, to ensure continuous information technology services, the
Board should enhance its business continuity plan to address all the issues
included in the GITA standard for such plans. The Board retains complaint
investigation and license application information only electronically, so it
does not have a way to recover the data in the event of a system failure;
therefore, its ability to ensure continuity in its operations is compromised.
The Board needs to ensure that the information will not be lost and can still
be accessed should the Board’s information technology systems shut
down.
3. The extent to which the Board has operated within the public interest.
The Board has generally operated within the public interest, including:
• Web site provides extensive information and services—The Board has
a Web site that provides information to the public on licensees and board
activities. The Web site includes information on choosing a doctor, including
a specific guide to selecting a cosmetic surgeon, and information about
licensed doctors such as their education and training, and past disciplinary
information. The Web site also provides information about how to file a
complaint, the complaint-handling process, scheduled public meetings,
upcoming meeting agendas, and meeting minutes. For licensees, the
Board’s Web site provides access to application forms and allows licensees
to renew their application on-line.
page 18
State of Arizona
• Complainants’ anonymity protected—The Board is complying with
statutory requirements to protect the identities of anonymous complainants.
Specifically, board management reported that as of April 2010, the Board
began providing copies of complaints where the complainant requests
anonymity to licensees with any identifying information redacted. A.R.S.
§32-1451(G) requires that the Board not disclose the name of any person
who files a complaint if that person requests anonymity. Prior to April 2010,
according to board staff, it sent a summary of any complaints to licensees
where the complainant requested anonymity, and it may still send a
summary if the original complaint contains an abundance of information
identifying the complainant. However, board staff indicated that this rarely
occurs.
Auditors did identify one way in which the Board's procedures could be changed
to help it operate more effectively in the public interest:
• Board needs to provide additional public information on its Web site—
Statute requires the Board to provide the public with information on
licensees in response to a written request for information and on its Web
site. Auditors found that the Board’s procedures for responding to written
requests are consistent with statute. Further, auditors placed four phone
calls to the Board between August 23, 2010 and September 8, 2010, and
found that board staff provided information about the status of a doctor’s
license, the doctor’s education and training, and any disciplinary and
nondisciplinary actions taken against the doctor. However, auditors’ review
of the Board’s Web site found it did not meet the statutory requirement for
providing licensee information related to malpractice or felony and
misdemeanor charges and convictions for the past 5 years. To address this
issue, the Board sought changes to its statutes. Laws 2011, Ch. 227, limits
the Board’s requirements to provide information about misdemeanors and
malpractice actions to those resulting in board disciplinary actions.
However, the law still requires that licensees notify the Board of all felony
convictions and that the Board immediately update its Web site upon
receiving this information. Laws 2011, Ch. 227, will go into effect in July
2011. The Board should ensure that it obtains required information from
licensees and updates its Web site as required by statute.
4. The extent to which rules adopted by the Board are consistent with the
legislative mandate.
General Counsel for the Auditor General has reviewed an analysis of the Board’s
rule-making statutes by the Governor’s Regulatory Review Council staff,
performed at auditors’ request, and believes that the Board has fully established
rules required by statute.
page 19
Office of the Auditor General
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to
its actions and their expected impact on the public.
The Board informs the public of proposed rules through Notices of Proposed
Rule Making filed with the Secretary of State’s Office and published in the
Arizona Administrative Record. For example, in July 2008, the Board filed a
Notice of Proposed Rule Making for changes it was making to its application
and licensing fee rules. The Board also obtains input from professional
associations and other stakeholders during the process of drafting rules and
incorporates their feedback into its rules.
In addition to involving the public in the rule-making process, the audit also
found that the Board involved the public in the process of revising its Pain
Management Guidelines in 2006. These guidelines constitute the Board’s policy
for the treatment of chronic pain by doctors. Specifically, the Board held a public
meeting in March 2006 to solicit feedback on the proposed adoption of the
Federation of State Medical Board’s model pain management guidelines and
other pain management guidelines. Board documentation indicates that the
Board incorporated feedback received from the public and stakeholders into its
guidelines. The guidance was revised in an effort to encourage doctors to
administer controlled substances in the course of treating pain without fear of
disciplinary action from the Arizona Medical Board.
As required by open meeting law, the Board has posted meeting notices and
board meeting agendas on its Web site at least 24 hours in advance and has
provided meeting minutes within 3 working days after the meeting. In addition,
the Board has posted a statement on its Web site stating where all its public
meeting notices will be posted.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
The Board has sufficient statutory authority to investigate and adjudicate
complaints within its jurisdiction and has various nondisciplinary and disciplinary
options available to use. However, as indicated in Sunset Factor 2 (see pages
16 and 17), the Board has not processed all complaints in a timely manner and
should take steps to ensure that it processes complaints in a more timely
manner, including developing a report to capture additional complaint-handling
timeliness information.
page 20
State of Arizona
7. The extent to which the Attorney General or any other applicable agency
of state government has the authority to prosecute actions under the
enabling legislation.
A.R.S. §41-192 authorizes the Attorney General’s Office to prosecute actions
and represent the Board. Board management reported that the Board retains
two full-time Assistant Attorneys General as legal representatives. One acts as
the Board’s legal representative during board meetings and general counsel in
day-to-day matters that come before the Board. The other represents the Board
for cases that go to formal hearings.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes, which prevent it from fulfilling its statutory mandate.
The Board has sought statutory changes to address deficiencies in its statutes.
Specifically:
• In 2006, A.R.S. §32-1451 was amended to allow the Board to issue
nondisciplinary orders for continuing medical education (CME). Previously,
a board requirement to obtain CME was considered a disciplinary action.
According to board management, this resulted in reporting the action to the
National Practioner’s Database and increased malpractice fees for some
doctors. However, 2007 statutory amendments gave the Board more
flexibility regarding the type of CME the Board could require and clarified
that a CME requirement could be disciplinary or nondisciplinary.
• In 2011, various board statutes were revised by Laws 2011, Ch. 227. For
example, the Legislature amended A.R.S. §32-1401 to allow doctors to
write prescriptions or issue prescription medications to a member of a
patient’s household without first conducting a physical examination or
establishing a doctor-patient relationship with the household member if the
prescription or medication is for an immunization or vaccine. In addition,
changes to A.R.S. §32-1401.03 modified the Board’s responsibility to post
on its Web site (or provide in writing when requested) felony, misdemeanor,
and malpractice information about licensees (see Sunset Factor 3, page
18).
Additionally, Laws 2011, Ch. 227, eliminated a board requirement to
provide nondisciplinary information on its Web site. This brought the
Board’s statutes into alignment with A.R.S. §32-3214, which prohibits
health profession regulatory boards from providing nondisciplinary
information on Web sites on or before January 1, 2012. According to board
management, the Board is working to modify its computer system, which
is used to populate information on its Web site, to ensure the Board is in
page 21
Office of the Auditor General
compliance with the new requirement. The Board anticipates the changes
will be completed by the end of calendar year 2011.
• Also in 2011, the Legislature passed Laws 2011, Ch. 97, which modified
A.R.S. §32-2842 by aligning state requirements for doctors who interpret
mammographic images with federal requirements. Specifically, this statutory
change will now require licensed doctors who interpret mammograms to
meet the federal education and training requirements for doing so.
The Board also reported that it has frequently sought to address deficiencies in
its statutes and taken action through the use of substantive policy statements to
reinforce stakeholder awareness and understanding of the statutes. For
example, in June 2008, the Board adopted the Duties of Hospitals and
Physicians to Report Peer Review/Quality Assurance Information Substantive
Policy Statement, which clarifies the statutory duties of hospitals and doctors to
promptly report unprofessional conduct among doctors.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors in the sunset law.
The audit did not identify any needed changes to board statutes.
10. The extent to which the termination of the Board would significantly harm
the public’s health, safety, or welfare.
Terminating the Board and its regulation of doctors would significantly endanger
the public health, safety, and welfare if this regulatory responsibility were not
transferred to another entity. Auditors reviewed complaints the Board handled
that posed a threat to the public’s health, safety, and welfare, including practice
below the standard of care, substance abuse issues, and sexual misconduct.
Without a regulatory licensing function of allopathic doctors in Arizona, there is
less assurance that unqualified or incompetent doctors are excluded from
practice. In addition, without a regulatory complaint investigation and adjudication
function, there are fewer mechanisms to discipline doctors who cause harm.
Finally, without regulation, consumers would not have a source of information
about Arizona doctors’ qualifications and their complaint and disciplinary
history.
page 22
State of Arizona
11. The extent to which the level of regulation exercised by the Board is
appropriate and whether less or more stringent levels of regulation would
be appropriate.
The audit found that the current level of regulation the Board exercises is
appropriate.
12. The extent to which the Board has used private contractors in the
performance of its duties and how effective use of private contractors
could be accomplished.
The Board has entered into contracts and agreements and used
intergovernmental service agreements to perform activities beyond its staff
resources and abilities. For example, the Board uses medical consultants to
review complaints. Also, it contracts for some information technology services
to provide technical support for its licensing and complaint-handling software.
Additionally, as authorized by statute, the Board contracts with a third-party
group to administer its Monitored Aftercare and Physician Health Programs.
These integrated programs provide for the confidential treatment and
rehabilitation of doctors who are impaired by alcohol or drug abuse, or who
have medical, psychiatric, psychological or behavioral health disorders that may
impact a licensee’s ability to safely practice medicine or perform healthcare
tasks. According to board staff, there are usually an estimated 100 licensees
enrolled and participating in the integrated programs. As of April 15, 2011, there
were 99 licensees participating.
This audit did not identify any additional opportunities for the Board to contract
for services.
Office of the Auditor General
Methodology
This appendix provides
information on the methods
auditors used to meet the
audit objectives.
This performance audit was
conducted in accordance
with generally accepted
government auditing
standards. Those
standards require that we
plan and perform the audit
to obtain sufficient,
appropriate evidence to
provide a reasonable basis
for our findings and
conclusions based on our
audit objectives. We
believe that the evidence
obtained provides a
reasonable basis for our
findings and conclusions
based on our audit
objectives.
The Auditor General and
staff express appreciation
to the members of the
Arizona Medical Board and
its Executive Director and
staff for their cooperation
and assistance throughout
the audit.
Auditors used the following specific methods to meet its audit objectives:
• To determine whether the Board’s processes and practices helped
ensure appropriate complaint handling, auditors interviewed board
members, management, and staff; reviewed policies, procedures, and
statutes; analyzed information from calendar year 2010’s regular
board meeting minutes; and obtained computerized information
system data for complaints dismissed or sanctioned during fiscal year
2010, including dates for when the Board’s investigation began and
when the complaint was resolved. In addition, auditors reviewed a total
of 22 complaints that were completed between August 2009 and
February 2011. Seventeen of these 22 complaints were selected to
review and assess the Board’s entire complaint-handling process,
including the medical consultant selection and review processes.
These 17 complaints, which included 10 in which a consultant had
been used, consisted of the following:
° Five randomly selected complaints resulting in advisory letters,
which are nondisciplinary.
° Five randomly selected complaints resulting in less severe
disciplinary action, such as a letter of reprimand and probation.
° Five judgmentally selected complaints dismissed by the Executive
Director where the complainant asked the Board to review the
decision.
° The two most recent complaints from the time period reviewed
resulting in revocation.
Auditors reviewed another five complaints in addition to the 17
included in the sample. These five involved allegations regarding the
appropriate prescribing of pain management medications and were
examined solely to assess consultant selection. The five pain
management complaints were identified by board staff because the
Board’s computer system could not be queried for this information,
and were reviewed in response to concerns provided by the profession
and Legislature regarding how the Board handles pain management
complaints.
page a-i
APPENDIX A
page a-ii
State of Arizona
• Auditors’ work on internal controls focused on the Board’s policies, procedures,
and practices established for the complaint-handling process including those
related to timely processing of complaints. Information system data was used
to determine complaint-handling timeliness, so auditors conducted data
validation test work to ensure that the system information auditors used was
sufficiently complete and accurate for the purpose of determining complaint-handling
timeliness. Auditors interviewed staff who use the data, observed data
entry procedures, and identified some specific controls over data accuracy and
reliability. Also, auditors ensured that 17 complaints listed in board meeting
minutes were contained in the computer system and that dates contained in the
computer system for these same 17 complaints matched meeting minutes. In
addition, board data was used to determine license-issuing timeliness, so
auditors also conducted data validation test work to ensure that licensing data
was reasonably complete and accurate. Specifically, auditors verified board
license application timeliness report information against 10 randomly selected
licensee’s files to ensure accuracy. Also, to assess completeness, auditors
randomly selected 20 licensee files from an April 2011 board computer system
report and ensured that information from those 20 files was contained on the
Board’s license application timeliness report. In general, auditors concluded
that the Board’s complaint handling and licensing data was sufficiently reliable
for audit purposes.
• Auditors also used some additional methods to obtain information used
throughout the report, including the Introduction section and Sunset Factors.
Specifically, auditors observed three board meetings held on June 9 and 30,
2010, and October 14, 2010. In addition, auditors compiled unaudited
information from the Arizona Financial Information System (AFIS) Accounting
Event Transaction File for fiscal years 2008 through 2010 and the AFIS
Management Information System Status of General Ledger—Trial Balance
screen for fiscal years 2009 and 2010, and board estimates for fiscal year 2011
as of May 2011; placed four anonymous public information request phone calls
to board staff between August 23, 2010 and September 8, 2010; and reviewed
an analysis of the Board’s administrative rules performed by the Governor’s
Regulatory Review Council staff and a board notice of proposed rulemaking
filed with the Secretary of State’s Office.
AGENCY RESPONSE
Janice K. Brewer
Governor
Douglas D. Lee, M.D.
Arizona Medical Board Chair
9545 E. Doubletree Ranch Road • Scottsdale, AZ 85258-5514
Telephone: 480- 551-2700 • Toll Free: 877-255-2212 • Fax: 480-551-2704
Website: www.azmd.gov
Lisa S. Wynn, B.S.
Executive Director
June 14, 2011
Debra K. Davenport, CPA
Auditor General
Office of Auditor General
State of Arizona
2910 N. 44th Street, Ste. 410
Phoenix, AZ 85018
Dear Ms. Davenport,
On behalf of the Arizona Medical Board, I have submitted the agency’s response to the Audit Report
conducted by your office.
The Arizona Medical Board and its staff sincerely appreciate the time and resources committed by the
audit team to understand the complex nature of the procedures used to balance preserving the due
process rights of licensees without compromising our core function of protecting the public.
I would also like to take this opportunity to recognize the professionalism of your staff throughout the
audit process. The recommendations identified in the report, which have either been implemented or
are in the process of being implemented, will allow the agency to continue in its ongoing commitment to
excellence in the regulatory oversight of health professionals under the jurisdiction of the board.
Thank you, again, for your consideration.
Respectfully,
Lisa S. Wynn
cc: Arizona Medical Board Members
Final Audit Response
Arizona Medical Board
June 14, 2011
Finding 1: The Board should improve staff doctor and medical consultant selection, and medical
consultant training and problem resolution practices.
The Board and its staff recognize the critical role played by staff doctors and medical consultants who
conduct clinical reviews of cases. In response to this audit, the Board has developed written policies to
enhance the quality of our pool of medical consultant volunteers, improve our process for selecting
consultants for each case, and ensure that consultants receive adequate training,
Recommendations:
1.1 The Board should formalize its staff doctor and medical consultant selection practices in written
policies and procedures, including how board staff should consider the nature of the complaint
and licensees’ practice specialties in determining the selection of consultants.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.2 The Board should establish and implement policies and procedures regarding medical
consultant qualifications, and complaint review time frames and requirements.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.3 The Board should establish and implement a process for requiring and ensuring that its medical
consultants complete board-provided training before they review complaints. One way to do
this would be to request confirmation from the consultants that they had reviewed the training
materials.
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Implementation will be complete by August 2011. The Board was recognized by the Federation of State
Medical Boards in 2011 in its national bi-weekly publication for its best practice of on-line medical
consultant training. In April 2010, Administrators in Medicine (AIM), a national association of medical
board administrators, recognized the Board for its Outside Medical Consultant Recruitment and
Education efforts as a Best of Boards honorable mention recipient.
1.4 The Board should establish and implement written policies and procedures that provide
guidance on when medical consultants should not be used or should be used only for certain
types of complaints.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.5 The Board should establish and implement policies and procedures on how and where problems
with specific medical consultants’ work and decisions regarding the continuing use of these consultants
should be documented.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. This information is being entered into our data system on the profile of the consultant.
We are utilizing a comments field to document if a consultant should not be utilized, or should be
utilized only in certain types of cases, and why.
Sunset Factors
• Executive Director complaint dismissals appear appropriate, but additional guidance should be
established in policy.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. The Board has established a policy that identifies the steps its Executive Director takes
when deciding whether to dismiss a complaint. The policy includes the steps taken when the Executive
Director denies a staff recommendation for dismissal and sends the case for further investigation.
• Changes are needed to address complaint-handling timeliness.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. The Board has strived to maintain excellent response time, both in the issuance of
licenses and the completion of complaint investigations. A portion of the complaint resolution
timeframe is dependent on the provision of due process for the physician. Once a case has been
referred to Formal Hearing, the Office of the Attorney General becomes responsible for preparing and
scheduling it for hearing pursuant to timeframes established in A.R.S. § 41.1092.05. The Board has
revised internal reports that track the timeliness of the handling of the complaint, including the priority
level and post-investigation timeframes.
• Board needs to improve two IT processes.
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Board Chief Information Officer developed the Board’s first IT Strategic Plan in 2010, and has
continually updated it as needs are prioritized and resources become available. Both processes
identified here are on the current IT Strategic Plan (Data Loss Prevention/Identity and Access
Management/Disaster Recovery) with Disaster Recovery projected to be completed by June 30, 2011
and the others projected to be completed in FY2012. The Board has significantly improved the security
posture of the agency and in May 2011 was recognized by the International Data Group’s
Computerworld Honors Program as a 2011 Laureate for the Board’s Security Awareness initiatives.
• Board needs to provide additional public information on its Web site.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. It would be extremely unusual for a physician to have a felony conviction and not have
either a permanent or interim action on the physician profile as a result, but we have changed our policy
and process to ensure that all felony convictions are posted as soon as they are reported.
Future Performance Audit Division reports
Pinal County Transportation Excise Tax
Performance Audit Division reports issued within the last 24 months
10-04 Department of Agriculture—
Food Safety and Quality
Assurance Inspection Programs
10-05 Arizona Department of Housing
10-06 Board of Chiropractic Examiners
10-07 Arizona Department of
Agriculture—Sunset Factors
10-08 Department of Corrections—
Prison Population Growth
10-L1 Office of Pest Management—
Regulation
10-09 Arizona Sports and Tourism
Authority
11-01 Department of Public Safety—
Followup on Specific
Recomendations from Previous
Audits and Sunset Factors
11-02 Arizona State Board of Nursing
11-03 Arizona Department of Veterans’
Services—Fiduciary Program
09-06 Gila County Transportation
Excise Tax
09-07 Department of Health Services,
Division of Behavioral Health
Services—Substance Abuse
Treatment Programs
09-08 Arizona Department of Liquor
Licenses and Control
09-09 Arizona Department of Juvenile
Corrections—Suicide Prevention
and Violence and Abuse
Reduction Efforts
09-10 Arizona Department of Juvenile
Corrections—Sunset Factors
09-11 Department of Health Services—
Sunset Factors
10-01 Office of Pest Management—
Restructuring
10-02 Department of Public Safety—
Photo Enforcement Program
10-03 Arizona State Lottery
Commission and Arizona State
Lottery

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A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
Performance Audit and Sunset Review
Arizona Medical Board
Performance Audit Division
June • 2011
REPORT NO. 11-04
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to im-prove
the operations of state and local government entities. To this end, she provides financial audits and accounting services to
the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of school
districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Audit Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
Dale Chapman, Director
Dot Reinhard, Manager and Contact Person
Emily Chipman, Team Leader
Mike Devine
Rose Tarbell
Senator Rick Murphy, Chair
Senator Andy Biggs
Senator Olivia Cajero Bedford
Senator Rich Crandall
Senator Kyrsten Sinema
Senator Russell Pearce (ex officio)
Representative Carl Seel, Vice Chair
Representative Eric Meyer
Representative Justin Olson
Representative Bob Robson
Representative Anna Tovar
Representative Andy Tobin (ex officio)
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
MELANIE M. CHESNEY
DEPUTY AUDITOR GENERAL
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
June 23, 2011
Members of the Arizona Legislature
The Honorable Janice K. Brewer, Governor
Douglas D. Lee, M.D., Chair
Arizona Medical Board
Ms. Lisa Wynn, Executive Director
Arizona Medical Board
Transmitted herewith is a report of the Auditor General, A Performance Audit and Sunset
Review of the Arizona Medical Board. This report is in response to a November 3, 2009,
resolution of the Joint Legislative Audit Committee. The performance audit was conducted
as part of the sunset review process prescribed in Arizona Revised Statutes §41-2951 et
seq. I am also transmitting within this report a copy of the Report Highlights for this audit to
provide a quick summary for your convenience.
As outlined in its response, the Arizona Medical Board agrees with all of the findings and
reports that it has implemented or plans to implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on June 24, 2011.
Sincerely,
Debbie Davenport
Auditor General
Attachment
cc: Arizona Medical Board Members
The Board regulates medical doctors
through licensing and by investigating
complaints and taking appropriate
disciplinary or nondisciplinary action. The
Board also uses a private contractor to
administer two integrated programs
established to assist doctors who are
impaired by drug or alcohol abuse, or
who have medical, psychiatric,
2011
June • Report No. 11-04
Arizona Medical Board
Our Conclusion
The Arizona Medical Board
(Board) regulates medical
doctors through licensing
and investigating
complaints against them.
The Board should establish
written guidance for
executive director
complaint dismissals and
take steps to improve
complaint-handling
timeliness. The Board uses
staff doctors and medical
consultants to assist it in
investigating complaints
against doctors. The Board
should improve the staff
doctor/medical consultant
selection process and
ensure that consultants
complete training. The
Board should also develop
guidance on using medical
consultants whose
previous work may have
been inadequate.
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
Board regulates
medical doctors
psychological, or behavioral health
disorders that may impact their ability to
safely practice.
Board lacks guidance for executive
director dismissals—As authorized by
statute, the Board has delegated authority
to the Executive Director to dismiss
complaints. Although the Board generally
sustained the Executive Director’s
calendar year 2010 decisions, it has not
established policies and procedures to
guide the Executive Director’s decision
making, including what factors should be
considered when deciding whether to
dismiss a complaint.
Some complaints not resolved in a
timely manner—We have found that
health regulatory boards should generally
process complaints within 180 days from
the time the complaint is received to when
the board resolves it. However, our
analysis of board data showed that if the
Executive Director did not dismiss a
complaint, it generally took more than 180
days before it was resolved. To ensure
that it processes more complaints within
180 days, the Board needs additional
information that will allow it to determine
its overall timeliness. For example, the
Board has a report that provides
information only about timeliness of
complaint investigations, but it should
develop a report to capture additional
complaint-handling steps, such as the
date its Staff Investigational Review
Committee reviews the complaint before
forwarding the complaint to the Executive
Director for dismissal or to the Board for
review and/or final action. The Board
should use this information to address
factors within its control that cause delays
in the complaint-handling process.
Recommendations:
The Board should:
• Adopt written policies and procedures
its Executive Director can use in decid-ing
whether to dismiss a complaint.
• Develop a report to capture additional
complaint-handling timeliness informa-tion
and use the information to
address timeliness issues.
Board should enhance executive director
complaint dismissal guidance and improve
complaint-handling timeliness
REPORT
HIGHLIGHTS
PERFORMANCE AUDIT
June 2011 • Report No. 11-04
A copy of the full report is available at:
www.azauditor.gov
Contact person:
Dot Reinhard (602) 553-0333
According to board management, in addition to
staff investigators who review professional conduct
complaints, the Board has one full-time and three
part-time staff doctors who review quality-of-care
and, in limited cases, professional conduct
complaints. According to board staff, for complaints
where these doctors do not have the time or
needed expertise or have a conflict of interest, the
Board will choose a medical consultant from among
almost 1,500 doctors who have volunteered their
services and meet certain qualifications established
by the Board. A consultant receives $150 to review
a complaint and advise the Board whether the
doctor under investigation deviated from the
standard of care. According to board information,
approximately 380 medical consultants reviewed
about 870 complaints in fiscal year 2010.
Board lacks clear guidance on how to select a
staff doctor or medical consultant—Based on our
review of a sample of complaints, most
assignments were made because the staff doctor’s
or consultant’s expertise was the same as that of
the doctor under investigation. However, in some
cases, the reasons for selecting a staff doctor or
consultant were not documented. Because a
formalized process helps ensure that the Board’s
intentions are carried out, the Board should
establish criteria in policies and procedures for
selecting staff doctors or consultants with the
appropriate expertise to review complaints.
Board should ensure that consultants complete
training—The Board provides its consultants with
training materials that provide guidance on how to
identify the standard of care, how to determine
whether the doctor deviated from the standard, and
what information to include in the report that the
consultant prepares. However, the Board does not
require or verify that consultants complete the
training before reviewing complaints.
Guidance is needed on what to do when a
consultant’s work is inadequate—Sometimes a
consultant is not qualified to review a complaint or a
consultant’s report is inadequate.
For example, in one complaint, the consultant did
not address all of a complainant’s concerns, and in
another complaint, a consultant provided
inconsistent information on whether the doctor
deviated from the standard of care.
Board staff and the Board have opportunities to
review medical consultant reports, and these
reviews have identified concerns. According to
board staff, new consultants can be selected if
concerns are identified. In addition, staff reported
that licensees sometimes raise concerns about a
consultant’s conflict of interest or applying the
appropriate standard of care. If these concerns
have a sound basis, board staff will request that
another consultant review the complaint.
However, when these instances occur, staff have no
guidance on whether or not to use the same
consultant again. Consequently, staff sometimes
give consultants a second chance. This may be
appropriate, such as when a report is late because
of unforeseen circumstances; however, it may not
be appropriate if the consultant failed to recuse
himself/herself because of a conflict of interest. In
addition to lacking guidance, the Board does not
adequately document problems with consultants’
work in its computer system. Without adequate
information in the system, it may not be clear
whether a medical consultant should be used
again.
Recommendations:
The Board should:
• Formalize the staff doctor and medical consul-tant
selection process in policies and proce-dures.
• Require that consultants complete the board
training before reviewing complaints.
• Provide guidance on when consultants should
not be used again and where this information
should be documented.
Board should formalize and enhance staff doctor and
medical consultant processes
Arizona Medical Board
Office of the Auditor General
TABLE OF CONTENTS
page i
Introduction 1
Finding 1: Board should improve staff doctor and medical
consultant selection, medical consultant training,
and problem resolution practices 7
Staff doctors and medical consultants review complaints 7
Qualification and selection practices should be formalized 7
Board should require and ensure medical consultants complete training 9
Board should develop additional guidance for using
medical consultants again after problems develop with their work 10
Recommendations 11
Sunset factor analysis 13
Appendix A: Methodology a-i
Agency Response
Figure
1 Summary of Complaint-Handling Process 3
Table
1 Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2008 through 2011 6
concluded
State of Arizona
page ii
Board responsible for regulating licensed
medical doctors
The Office of the Auditor
General has conducted a
performance audit and
sunset review of the
Arizona Medical Board
(Board) pursuant to a
November 3, 2009,
resolution of the Joint
Legislative Audit
Committee. This audit was
conducted as part of the
sunset review process
prescribed in Arizona
Revised Statutes (A.R.S.)
§41-2951 et seq. This
performance audit and
sunset review of the Board
focused on determining
whether the Board’s
complaint-handling
processes and practices
helped ensure that
complaints were
appropriately investigated,
adjudicated, sanctioned,
and processed in a timely
manner. This report also
includes responses to the
sunset factors specified in
A.R.S. §41-2954.
Board mission
The Board regulates the practice of allopathic medicine in Arizona
through licensure and complaint investigation and resolution related to
medical doctors, or MDs. According to A.R.S. §32-1403(A), “The
primary duty of the board is to protect the public from unlawful,
incompetent, unqualified, impaired or unprofessional practitioners of
allopathic medicine through licensure, regulation and rehabilitation of
the profession in this state.”
Licensing requirements
The Board is responsible for issuing licenses to practice medicine to
qualified applicants, and biennially issuing renewal licenses to qualified
active license holders who
seek renewal. During fiscal
year 2010, the Board issued
1,275 initial licenses and
9,722 renewals. According
to board documentation, as
of February 2011, there were
21,110 actively licensed
doctors in Arizona.1 License
applicants must successfully
pass all three parts of the
United States Medical
Licensing Exam or other
statutorily approved exams
and meet ten statutory
requirements (see textbox
for examples of the
1 According to a board official, this number does not include teaching licenses, educational teaching
permits, training permits, dispensing registrations, locum tenens registrations, or pro bono
registrations. A locum tenens registration authorizes an out-of-state doctor to temporarily assist or
substitute for an Arizona doctor. A pro-bono registration allows doctors who are not licensees to
practice in Arizona for 60 days provided that they meet certain requirements, such as not being the
subject of an unresolved complaint.
page 1
Office of the Auditor General
a
Licensing requirements
According to A.R.S. §32-1422, applicants
for licensure must meet ten basic
requirements, including:
• Graduating from an approved school
of medicine;
• Successfully completing an approved
12-month hospital internship,
residency, or clinical fellowship
program;
• Having the physical and mental
capability to safely engage in the
practice of medicine; and
• Paying all fees required by the Board.
Source: Auditor General staff analysis of A.R.S. §32-
1422.
Scope and Objectives
Introduction
page 2
State of Arizona
requirements).1 License applicants must pay a $500 initial license application fee
and, if the application is approved, a $500 issuance fee, which may be prorated from
date of issuance to date of license renewal.2 Doctors renewing their license must
attest that they have completed required continuing medical education and pay a
$500 renewal fee.3
Complaint-handling process
The Board is also responsible for investigating
and adjudicating complaints against licensed
doctors and taking appropriate disciplinary or
nondisciplinary action. A.R.S. §32-1451 states
that the Board may investigate any evidence
that may show that a doctor is or may be
medically incompetent, is or may be guilty of
unprofessional conduct, or is or may be mentally
or physically unable to safely engage in the
practice of medicine. As outlined in Figure 1
(see page 3), the complaint-handling process
involves several steps, including an investigation
to determine whether it appears that the
allegations in a complaint are supported and a
review of the complaint and investigation
material by board management before being
sent to the Executive Director or Board for
further review and action.
After completing an investigation, the Executive
Director or Board may dismiss the complaint, or
the Board may take several other nondisciplinary
and disciplinary actions (see textbox). According
to board data, the Board received approximately
1,035 complaints during fiscal year 2010 that
were within its jurisdiction. Board data also
1 According to the American Medical Association Web site, some medical students and doctors completed other
national exams prior to the implementation of the United States Medical Licensing Exam in 1994. A.R.S. §32-1426
permits the Board to grant licenses to applicants who completed exams prior to implementation of the United States
Medical License Exam.
2 A.R.S. §32-1436 requires that the Board annually establish by a formal vote nonrefundable license issuance and
renewal fees. Although a review of the Attorney General Handbook found that the Board should establish its fees in
administrative rule, the Board has not done so due to a moratorium on rule making. As a result, the Board’s rules have
not been updated to reflect its changed fees.
3 According to board management, licensees are asked to attest whether or not they have completed required
continuing medical education requirements. However, licensees are required to submit proof of completing the
continuing medical education requirements if selected as part of an audit to determine compliance. Board policy
establishes that 5 percent of licensees will be audited each year.
Board nondisciplinary and disciplinary
options
Nondisciplinary options:
• Require continuing medical education.
• Issue an advisory letter.
Disciplinary options:
• Require continuing medical education.
• Enter into an agreement to restrict or limit
the doctor’s practice or professional
activities or to rehabilitate, retrain, or assess
the doctor.
• Issue a letter of reprimand.
• Issue a decree of censure. A decree of
censure is an official action against the
doctor’s license and may include a
requirement for restitution of fees to a patient
resulting from violations of statutes or rules.
• Impose a civil penalty of not less than
$1,000 or more than $10,000 for each
violation of statute or rule.
• Fix a period and terms of probation.
• Suspend or revoke a license.
Source: Auditor General staff analysis of A.R.S. §32-1451.
page 3
Office of the Auditor General
Source: Auditor General staff analysis of the Board’s complaint-handling process.
Figure 1: Summary of Complaint-Handling Process
Complaint Received
Complaint received and intake
process completed. (See Box A)
Complaint Investigated
Complaint investigation
completed. (See Box B)
Investigation Reviewed
Supervisor reviews complaint
investigation and requests
further investigation as needed.
(See Box C)
SIRC Review and
Recommendation
The Staff Investigational
Review Committee (SIRC)
reviews the complaint and
requests further investigation
as needed.
SIRC recommends one of
three outcomes. SIRC also
notifies the licensee of
nondisciplinary or disciplinary
recommendations.
(See Box D)
Outcome 3:
OAH reviews license revocation
or suspension
recommendations
All cases for which the Board
recommends license revocation
or suspension for longer than 12
months are sent to OAH. The
Board considers OAH’s resulting
recommendation when making its
final decision on complaint
resolution.
Outcome 2:
Board reviews a limited number
of dismissal recommendations
and all recommendations other
than license suspensions for
longer than 12 months or
revocations
The Board reviews and approves,
rejects, or modifies SIRC
recommendations and consent
agreements, or may hold formal
interviews if chosen by the
licensee. At this point, the Board
may request additional
investigation, dismiss the
complaint, take nondisciplinary or
disciplinary action, or refer the
case to OAH.
Outcome 1:
Executive Director reviews
majority of dismissal
recommendations
The Executive Director reviews
complaint investigation materials,
including the investigation report,
to determine whether or not to
dismiss the complaint. Licensees
and complainants are notified of
the dismissal decision.
Complainants may request that the
Board review the Executive
Director’s dismissal decisions.
Box B: Complaint Investigation
1. Staff investigator reviews professional conduct evidence. Medical
consultant or on-staff doctor is selected to review quality-of-care
evidence. (For more information about consultants, see Finding 1,
pages 7 through 12.)
2. Staff/consultant writes report concluding on whether the
investigation indicates violations of law or deviations from the
standard of care.
Box C: Investigation Review
The Chief Medical Consultant reviews quality-of-care complaints,
and the Investigations Manager reviews professional conduct
complaints for investigation adequacy and completeness.
These reviewers may:
1. Recommend Executive Director dismissal, or
2. Forward the complaint to SIRC.
Box D: Sanction Options for Licensees
For disciplinary recommendations other than license revocations or
suspensions longer than 12 months, the licensee is notified that
he/she may opt to sign a consent agreement, participate in a
formal interview with the Board, or request that the complaint be
heard by the Office of Administrative Hearings (OAH).
Box A: Complaint Intake Process
Staff review a complaint to determine if it falls within the Board’s
jurisdiction and refer the complaint to a staff investigator. The
investigator assigns a priority based on the seriousness of
allegations; assesses whether the complaint is about quality-of-care
or professional conduct; contacts the complainant to confirm
allegations; notifies doctor(s) named in complaint; and requests
relevant investigation information, such as medical records and
subsequent treating doctor records.
page 4
State of Arizona
shows that the Board investigated and took action on 954 complaints. The Executive
Director dismissed 650 of the 954 complaints, while the Board dismissed 19 of these
complaints.1 In addition, the Board issued 113 advisory letters; 12 orders for
nondisciplinary continuing medical education; 44 disciplinary actions including
letters of reprimand, decrees of censure, probation, or a combination of these
options; and forwarded 1 complaint to formal hearing with the Office of Administrative
Hearings.2 Although the Board did not revoke or suspend a license, 8 licensees
surrendered their licenses.3
Monitored Aftercare and Physician Health Programs
As authorized by statute, the Board has established confidential programs to assist
doctors who are impaired by alcohol or drug abuse, called the Monitored Aftercare
Program, or who have medical, psychiatric, psychological, or behavioral health
disorders that may impact their ability to safely practice medicine or perform
healthcare tasks, called the Physician Health Program. The Board established the
Monitored Aftercare Program in 1987 and the Physician Health Program in 2004, and
integrated the two programs in 2010. The Board uses a private contractor to
administer the integrated programs. According to board staff, there are usually
around 100 licensees enrolled and participating in the integrated programs, and as
of April 15, 2011, 99 licensees were enrolled in the programs. Board management
reported that the integrated programs are paid for by the licensees in the programs.
Board’s role in monitoring medical marijuana
In November 2010, Arizona voters passed the Arizona Medical Marijuana Act. This
citizen initiative—Proposition 203—required the Arizona Department of Health
Services (Department) to create a medical marijuana program within 120 days from
the official election results. According to board management, the program will not
affect its licensing of qualified doctors, but it will affect complaint handling because
the Department will send information to the Board about licensees who are not
following the medical marijuana program rules. Board management reported that
1 A.R.S. §32-1405(C)(21) allows the Board to authorize its Executive Director to dismiss complaints that are without merit.
2 The Board may issue an advisory letter if there is insufficient evidence to support disciplinary action, but continuation of
the licensees’ activities could result in further board action; if the violation is a minor or technical violation that is not of
sufficient merit to warrant disciplinary action; or if the licensee has demonstrated substantial compliance through
rehabilitation or remediation that mitigates the need for disciplinary action.
3 The Board took other action on 107 complaints, such as limiting a licensee’s practice or requiring licensee evaluations
during the investigation of a complaint, and administratively closing complaints. Board management reported that the
Board administratively closes complaints when there is insufficient evidence to support that a violation occurred, but
the allegations are serious enough that the Board would need to reopen the complaint if additional information was
later provided.
page 5
Office of the Auditor General
they have worked closely with the Department on the new rules for the program.
Although board management reported that they anticipate some increase in the
number of complaints referred to the Board for investigation, the Board should have
the resources to handle a moderate workload increase. However, board management
reported possible challenges in obtaining medical consultants to review complaints
related to standard of care because medical marijuana is an emerging practice.
Organization and staffing
As prescribed in A.R.S. §32-1402(A), the Board consists of 12 governor-appointed
members, including 8 who are actively practicing medicine and 4 who represent the
public. One of the four public members is required to be a licensed practical or
professional nurse. Board members serve 5-year terms. The Board is required to
meet at least quarterly, but in practice it convenes every other month to hear
information from the public, obtain updates from its Executive Director and legal
advisor, and take action on complaints. The Board was appropriated 58.5 full-time
equivalent (FTE) staff for fiscal year 2011. However, as of April 2011, it was assisted
in its duties by 35.5 FTE staff, including an Executive Director, Deputy Executive
Director, complaint investigators, licensing staff, and other support staff.
Budget
The Board does not receive any State General Fund monies. Rather, the Board’s
revenue mainly comes from license application and renewal fees. The Board is also
required to remit 10 percent of all its revenues to the State General Fund. As shown
in Table 1 (see page 6), during fiscal year 2010, the Board received approximately
$6.7 million in revenues and remitted approximately $675,000 to the State General
Fund. The Board’s expenditures have declined from approximately $5.9 million in
fiscal year 2008 to less than $5 million in fiscal year 2010. The Board estimates its
expenditures will total a little more than $5 million in fiscal year 2011. The Board
spends nearly two-thirds of its monies for personnel costs, including employee-related
costs. Table 1 also shows the Board was required to transfer approximately
$1.4 million of its available resources to the State General Fund during fiscal year
2008. Smaller transfers were also required in fiscal years 2009 through 2011 (see
Table 1, footnote 3). The transfers significantly decreased the Board’s fund balance;
however, through increased revenues and expenditure reductions, the Board’s fund
balance at the end of fiscal year 2010 has nearly reached its pre-transfers level. The
Board estimates that it will have an ending fund balance of nearly $2.9 million in fiscal
year 2011.
page 6
State of Arizona
Table 1: Schedule of Revenues, Expenditures, and Changes in Fund Balance
Fiscal Years 2008 through 2011
1 Amount is net of approximately $12,800, $32,700, $81,600, and $100,900 for fiscal years 2008, 2009, 2010, and 2011,
respectively, for convenience fees the Board collected for online and credit card payments.
2 As required by A.R.S. §32-1406, the Board remits to the State General Fund 10 percent of all revenues.
3 Amount consists of transfers to the State General Fund in accordance with Laws 2008, Ch. 53, §2 and Ch. 285, §46 and Laws
2010, 7th S.S., Ch. 1, §148.
Source: Auditor General staff analysis of the Arizona Financial Information System (AFIS) Accounting Event Transaction File for fiscal
years 2008 through 2010; the AFIS Management Information System Status of General Ledger-Trial Balance screen for fiscal
years 2009 and 2010; and board-provided information for fiscal year 2011 as of May 12, 2011.
2008 2009 2010 2011
(Actual) (Actual) (Actual) (Estimate)
Revenues:
Licenses and fees $ 6,211,795 $ 6,504,774 $ 6,467,923 $ 6,599,400
Fines, forfeits, and penalties 154,399 145,332 144,886 129,400
Charges for goods and services 61,300 47,153 50,232 50,500
Other 14,909 20,793 43,675 3,800
Gross revenues 6,442,403 6,718,052 6,706,716 6,783,100
Net credit card and on-line transaction fees 1 (46,067) (56,418) (22,327) (4,600)
Remittances to the State General Fund 2 (649,072) (663,969) (675,039) (677,500)
Net revenues 5,747,264 5,997,665 6,009,350 6,101,000
Expenditures and transfers:
Personal services and related benefits 3,789,988 3,547,357 3,250,324 3,200,000
Professional and outside services 1,119,061 1,028,717 629,545 700,000
Travel 31,216 35,121 35,870 35,000
Food 4,816 3,124 1,792 1,000
Other operating 685,194 798,996 851,715 800,000
Equipment 287,859 114,420 164,386 321,900
Total expenditures 5,918,134 5,527,735 4,933,632 5,057,900
Transfers to the State General Fund 3 1,401,800 52,100 4,700 122,100
Transfers to Office of Administrative Hearings 34,531 24,432 8,317 20,000
Total expenditures and transfers 7,354,465 5,604,267 4,946,649 5,200,000
Net change in fund balance (1,607,201) 393,398 1,062,701 901,000
Fund balance, beginning of year 2,109,482 502,281 895,679 1,958,380
Fund balance, end of year $ 502,281 $ 895,679 $ 1,958,380 $ 2,859,380
Board should improve staff doctor and
medical consultant selection, medical
consultant training, and problem resolution
practices
The Arizona Medical Board
(Board) should take several
steps to strengthen its
practices for using staff
doctors and medical
consultants to review
complaints against
licensees. The Board uses
both staff doctors and
medical consultants—
licensed doctors who have
volunteered their services—
to review complaints.
However, auditors found
that board staff were
inconsistent in their
explanation and application
of board practices for
selecting staff doctors and
medical consultants. One
underlying reason appears
to be that many of these
practices are not formally
reflected in board policies
and procedures, and in
some cases, the practices
themselves need to be
enhanced. Issues needing
further attention include
criteria for selecting staff
doctors and medical
consultants, requirements
for ensuring that medical
consultants review training
materials provided to them,
and guidance for using
medical consultants again
if limitations in their work
result in the need to obtain
a review from a different
medical consultant.
Staff doctors and medical consultants review
complaints
In addition to staff investigators who review professional conduct complaints,
the Board uses both staff doctors and medical consultants to review
quality-of-care complaints and, on a more limited basis, professional
conduct complaints. According to board management, the Board has one
full-time staff doctor and three part-time staff doctors who review
complaints. The Board’s staff doctors are specialized in cardiology, internal
medicine, obstetrics and gynecology, anesthesiology, and pain
management. Board management reported that if the Board’s staff doctors
do not have the expertise or time needed to review a complaint or have a
conflict of interest with the licensee, a medical consultant will be chosen to
review the complaint.
Based on information provided by the Board, almost 1,500 Arizona-licensed
doctors have volunteered their services to the Board, but must
meet certain qualifications in order to be selected as a medical consultant
(see textbox, page 8). The Board pays medical consultants $150 for each
complaint they investigate. The Board requires medical consultants to
provide an opinion on whether or not a licensee deviated from the standard
of care within 4 weeks of sending the consultant information about how to
access investigative information. This opinion is based on a review of
investigative materials provided by board staff. According to information
provided by board management, the Board used approximately 380
medical consultants to review approximately 870 complaints during fiscal
year 2010.
Qualification and selection practices should be
formalized
The Board has not established clear guidance regarding the process for
assigning complaints to appropriate and qualified staff doctors or medical
page 7
Office of the Auditor General
FINDING 1
page 8
State of Arizona
consultants. When assigning a complaint to a staff doctor or medical consultant, staff
must first determine what specialty is needed for review of a complaint in order to
select a qualified staff doctor or consultant. However, when asked to describe how
they determine what type of specialty is needed, board staff provided different—and
somewhat conflicting—explanations. The absence of a clear and consistent
explanation was also borne out in the sample of complaints that auditors reviewed.
Specifically, staff doctors or medical consultants reviewed 15 of the 22 complaints in
a sample of complaints resolved between August 2009 and February 2011.1 For 12
of these 15 complaints, the staff doctor or medical consultant’s specialty matched
that of the licensee against whom the complaint had been filed. In the remaining 3
complaints, however, the specialty differed from the licensee’s, and the reasons for
choosing someone with a different specialty were not always apparent from the
complaint file. There may be appropriate reasons—such as the particular nature of
the complaint—for selecting a staff doctor or medical consultant with a different
specialty, but the reasons for these selections were not documented. According to
management, the staff doctor or medical consultants in these 3 complaints were
selected based on the particular nature of the complaint or for convenience.2
Clarifying the steps to be followed for selecting a staff doctor or medical consultant
and establishing them in written policies and procedures is important. Established
internal control standards indicate that policies and procedures help ensure that
1 See Appendix A, page a-i, for additional information about the sample of complaints auditors reviewed.
2 For the complaint in which the selection was based on convenience, board management reported that they had only
one on-staff doctor at its office at the time an investigative interview was held with a licensee and that they were
assigned the complaint because they had attended the interview and identified medical documents needed to
investigate the complaint. However, their specialty did not match that of the licensee or the nature of the complaint.
Board staff provided
different and somewhat
conflicting explanations
of how they select a staff
doctor or medical
consultant to review a
complaint.
Medical consultant qualifications and selection practices
Qualifications
• Possess an active Arizona medical license1
• Have no prior or pending board disciplinary action
• Have no real or potential conflict of interest
Selection practices
• Board staff investigators review the complaint to identify the specialty
needed
• A board staff member queries the Board’s database for a qualified
outside medical consultant
1 According to board management, the Board may use an out-of-state medical consultant if there
are so few people practicing within the State that any of them would have a conflict of interest in
reviewing another licensee’s complaint.
Source: Auditor General staff interview with board staff, and analysis of board Web site information
posted at http://www.azmd.gov/Files/OMC/OMC-Orientation/OMC-Orientation_files/frame.
htm
page 9
Office of the Auditor General
directives are carried out.1 Such policies and procedures can help ensure consistent
and appropriate staff doctor or medical consultant selection practices by clarifying
the factors that should be considered when determining what type of specialty is
needed. Therefore, the Board should formalize its staff doctor and medical consultant
selection practices in written policies and procedures, including how board staff
should consider the nature of the complaint and licensees’ practice specialties in
determining the selection of staff doctors or medical consultants. In addition,
although the Board has established medical consultant qualifications, complaint
review time frames, and requirements for medical consultant reports, these practices
have not been formalized in policies and procedures. Therefore, the Board should
establish and implement medical consultant qualifications, medical consultant
complaint review time frames, and report requirements in formal policies and
procedures.
Board should require and ensure medical consultants
complete training
The Board provides its medical consultants with training materials, but it should
ensure that consultants review these materials and verify they have done so. Once a
qualified medical consultant is identified, board staff provide the consultant a link to
training information located on its Web site. The training includes guidance on how
to identify the standard of care and determine whether or not a deviation has
occurred, what information should be included in the report that the consultant
prepares, examples of appropriate reports, and when the consultant should recuse
him/herself from reviewing the complaint. Reviewing this information can help ensure
that consultants conduct a thorough review of all complaint investigative material,
reach appropriate conclusions, and complete an appropriate and adequate
investigative report. However, the Board neither requires consultants to read these
materials nor has a process in place to determine whether they have done so. As a
result, it has no assurance that consultants understand the medical complaint review
requirements. Due to the importance of the training information provided, the Board
should establish and implement a process for requiring and ensuring that its medical
consultants complete the training before reviewing complaints, such as requesting
the consultants’ confirmation that they reviewed the training materials.
1 United States General Accounting Office. (1999). Standards for internal control in the federal government [GAO/AIMD-
00-21.3.1]. Washington, DC: Author.
Reviewing medical
consultant training can
help medical consultants
reach appropriate
conclusions.
page 10
State of Arizona
Board should develop additional guidance for using
medical consultants again after problems develop with
their work
If problems develop with a medical consultant’s work, the Board takes various
actions such as requesting that a different consultant review the complaint, but it has
not developed sufficient policies to consistently determine whether and how the
consultant can be used again. Board policies or practices allow staff, licensees, or
the Board to identify problems with medical consultants’ work. For example:
• Board policy indicates that the Board’s Chief Medical Consultant and its Staff
Investigational Review Committee review all medical consultant reports for
completeness and adequacy, and the three board members auditors interviewed
reported that it is their practice to also review medical consultant reports. These
reviews have identified medical consultant problems, including inadequate
consultant reports and unqualified consultants. Board staff reported that the
Board and its staff can obtain a new medical consultant review when it identifies
these problems. The sample of complaints reviewed by the auditors contained
two such examples where the Board or its staff identified consultant problems.1
In one complaint, the medical consultant did not address all of the concerns
identified by the complainant, and in the other complaint, the consultant
provided inconsistent information on whether the licensee deviated from the
standard of care. For both complaints, the Board or its staff requested that a
second medical consultant review the complaint.
• Licensees have an opportunity to identify concerns with medical consultants
when reviewing consultant reports. Specifically, according to board policy,
licensees are offered an opportunity to review the medical consultant report if
the consultant determines that there was a deviation from the standard of care.
In response to their review of the medical consultant report, licensees are
permitted to provide any new information about the complaint that they feel the
Board should consider. According to board management, licensees will
sometimes mention concerns about potential conflicts of interest or whether the
consultant applied an inappropriate standard of care. Management reported
that they will request a new consultant review of the complaint if it appears that
the licensee’s concerns about the consultant are sound.
Despite these policies and practices, when a review by licensees, the Board, or its
staff establishes that problems exist with a medical consultant’s work, staff do not
have guidance on how to decide whether or not to use the consultant again to review
other complaints. Board staff responsible for maintaining the Board’s list of volunteer
1 Auditors’ review of whether problems were identified with the medical consultant’s review of a complaint was limited to
6 of the 15 complaints in which a medical consultant had been involved. In the remaining complaints, the complaint
was reviewed by a staff doctor or auditors limited their review to assessing the consultant’s qualifications. See Appendix
A, page a-i, for further discussion.
Board member and staff
reviews of medical
consultant reports have
identified problems,
including inadequate
reports.
page 11
Office of the Auditor General
medical consultants reported generally making this determination without guidance,
and sometimes giving consultants a second chance before determining not to use
them again. This second-chance approach may be appropriate in some
circumstances, but not in others. For example, if the consultant was late in submitting
his/her report due to unforeseen circumstances, the Board may still be able to use
this consultant on a subsequent complaint. However, the Board may not want to use
a medical consultant who failed to appropriately recuse him/herself when a conflict
of interest existed. To ensure appropriate medical consultant selection, the Board
should establish and implement written policies and procedures that provide
guidance on when consultants should not be used again, or should be used only for
certain types of complaints.
Additionally, the Board does not adequately document problems identified with
medical consultants and decisions made on whether or not to use consultants again.
Specifically, the Board has not established policies and procedures on the steps to
be taken in documenting such problems, and board staff reported inputting limited
information about consultant-use decisions into the Board’s computer system.
Without adequate information in the system, it may not be clear whether a medical
consultant should be used again. For the two complaints in the auditors’ sample
where the Board or its staff decided to obtain a second consultant’s review, the
entries in the computer system’s field that staff review for information about concerns
with medical consultants did not contain information about these concerns.1
Although staff indicated that problems with consultants may be located in meeting
minutes or in other parts of the computer system, the board staff responsible for
maintaining the Board’s list of volunteer consultants does not consistently review
these other sources of information. Therefore, the Board should establish and
implement policies and procedures on how and where medical consultant problems
and decisions on their continuing use should be documented.
Recommendations:
1.1 The Board should formalize its staff doctor and medical consultant selection
practices in written policies and procedures, including how board staff should
consider the nature of the complaint and licensees’ practice specialties in
determining the selection of consultants.
1.2 The Board should establish and implement policies and procedures regarding
medical consultant qualifications, and complaint review time frames and
requirements.
1 In board meeting minutes, auditors identified three other complaints in which concerns had surfaced about a
consultant’s work. As with the two complaints in the sample, the information in the computer system did not contain
information about these concerns.
The Board does not
adequately document
consultant problems.
page 12
State of Arizona
1.3 The Board should establish and implement a process for requiring and
ensuring that its medical consultants complete board-provided training before
they review complaints. One way to do this would be to request confirmation
from the consultants that they had reviewed the training materials.
1.4 The Board should establish and implement written policies and procedures
that provide guidance on when medical consultants should not be used or
should be used only for certain types of complaints.
1.5 The Board should establish and implement policies and procedures on how
and where problems with specific medical consultants’ work and decisions
regarding the continuing use of these consultants should be documented.
Sunset factor analysis
According to Arizona
Revised Statutes (A.R.S.)
§41-2954, the Legislature
should consider several
factors in determining
whether the Arizona
Medical Board (Board)
should be continued or
terminated. Auditors’
analysis showed strong
performance by the Board
with regard to many of
these factors, but it also
showed a need to
strengthen procedures in
four areas, as follows:
• Formalizing policies for
determining when the
Executive Director can
dismiss a complaint (see
Sunset Factor 2, pages
14 through 15);
• Establishing complaint-monitoring
procedures
that encompass the
entire complaint
process, not just the
limited portion
addressed under current
procedures, to help
improve the timely
processing of
complaints (see Sunset
Factor 2, pages 16
through 17);
• Tightening controls over
sensitive information in
computer systems (see
Sunset Factor 2, page
17); and
• Ensuring it obtains
additional licensee
public information and
provides it on the Web
site as required by
statute (see Sunset
Factor 3, page 18).
1. The objective and purpose in establishing the Board.
The Board regulates the practice of allopathic medicine in Arizona
through licensure and complaint investigation and resolution related
to medical doctors, or MDs. According to A.R.S. §32-1403(A), “The
primary duty of the board is to protect the public from unlawful,
incompetent, unqualified, impaired or unprofessional practitioners of
allopathic medicine through licensure, regulation and rehabilitation of
the profession in this state.”
To accomplish this mission, the Board issues licenses to practice
medicine to qualified applicants, investigates and adjudicates
complaints against licensed doctors, takes disciplinary or
nondisciplinary action as appropriate, and provides information to the
public about licensees through various avenues, including its Web site
and over the phone.
2. The effectiveness with which the Board has met its objective and
purpose and the efficiency with which it has operated.
The Board has effectively met several of its prescribed purposes and
objectives, but needs improvement in some other areas. Some
examples in which the Board is effectively performing include:
• Licensing processes meet requirements—Statute requires
that specific information be included on an application form
provided to the Board, including whether any disciplinary action
has ever been taken against the applicant by another licensing
board, and medical college certification and postgraduate
training. Auditors reviewed the Board’s application form and
found it complies with statute. In addition, the Board processed
the initial license applications issued in fiscal year 2010 within the
120-day overall time frame required by administrative code.
According to the Board’s Administrative Rule R4-16-206, the
Board must conduct an administrative review of a license
application within 120 days of receipt to verify that the application
is complete. Auditors reviewed licensing data for the 1,275
license applications issued in fiscal year 2010 and found that all
but 3 licenses were processed within the 120-day time frame.1
1 For the three applications that the Board did not process within the 120-day time frame, two involved
deficient applications and one applicant was sent for investigation.
page 13
Office of the Auditor General
Sunset Factors
page 14
State of Arizona
Further, according to an April 2011 board report, the Board issued licenses
in January and February 2011 within an average of 37 and 21 days,
respectively.
• Board has established processes to help ensure complaint
investigations are complete and adequate—Board policy requires
several steps during the investigative process, including informing the
licensee of the complaint and requesting his or her response. In addition,
policy indicates that an investigative or medical consultant report
documenting the investigation’s outcome will be developed for each
complaint. In February 2011, the Board revised its investigative policy to
specify that its investigative manager must ensure that investigations are
adequate and complete. Finally, to further ensure the appropriateness and
adequacy of complaint investigation, board staff receive investigative
training.1
Auditors’ reviewed a sample of 17 complaints and found that the Board
followed the investigative steps outlined in its policies and procedures for
each of these complaints. For example, board staff notified both the
complainant and licensee of the receipt of the complaint, and conducted
necessary supervisory reviews for the completeness and adequacy of the
investigation. In addition, auditors reviewed board meeting minutes from
calendar year 2010 containing more than 300 complaints and identified
only 4 complaints where the Board requested additional investigation.
The Board has some sound practices in complaint handling and information
technology, but it can improve the effectiveness of these practices by making
various changes. Specifically:
• Executive Director complaint dismissals appear appropriate, but
additional guidance should be established in policy—A.R.S. §32-
1405(C)(21) permits the Executive Director, if delegated by the Board, to
dismiss complaints that are without merit, and A.R.S. §32-1405(E)
establishes that complainants can request the Board to review the
Executive Director’s decision to dismiss a complaint.2 The Board has
established various practices to help guide these dismissals. Specifically,
board policy requires that the Board’s investigations manager or chief
medical consultant review investigations to check for adequacy and
completeness of the investigation, and indicates that complaints with no
1 Staff attend Council on Licensure Enforcement and Regulation basic and advanced training. In addition, three of the
six staff investigators have taken the first part of a three-part training providing subject-specific education and training
for state medical board investigators, provided by Administrators in Medicine and the Federation of State Medical
Boards.
2 For executive director dismissal reviews, board members are provided with the initial complaint, all complaint
investigation materials, and any subsequent information submitted or obtained as part of or resulting from the
complainant’s request for board review. In addition, the licensee and complainant are permitted to address the Board
at the Board meeting during the Board’s Call to the Public and/or submit a written response for the Board’s
consideration.
page 15
Office of the Auditor General
violations will be submitted to the Executive Director for dismissal. Auditors
reviewed a judgmental sample of five executive director dismissals that the
Board reviewed in February 2011 and found that the investigative reports
provided to the Executive Director indicated there were no violations. In
addition, auditors’ review of meeting minutes from calendar year 2010
identified that the Board generally sustained the Executive Director’s
decisions. Specifically, the Board sustained 65 of the 68 decisions it
reviewed.1
Although the Board has established good practices for executive director
dismissal decisions, it lacks documented policy and procedures outlining
the steps its Executive Director should take when deciding whether to
dismiss a complaint. This was similarly discussed in the Auditor General’s
2004 performance audit (see Report No. 04-L1). Specifically, that audit
recommended that the Board implement policies to guide decision-making
during the complaint review process, including what factors
reviewers should consider when deciding whether to dismiss a complaint.
The Board has established policies and procedures for its complaint
reviewers, including its investigations manager, chief medical consultant,
and its Staff Investigational Review Committee, when recommending the
Executive Director dismiss a complaint or reviewing investigative staff’s
recommendations for the Executive Director’s dismissals. However, the
Board has not established policies and procedures guiding the Executive
Director’s decision-making process, such as what steps to take if there is
a disagreement with staff’s recommendation. Internal control standards
indicate that policies and procedures help ensure that directives are carried
out.2 Therefore, the Board should develop and implement a written policy
and procedures for the Executive Director to use in deciding whether to
dismiss a complaint, including what factors should be considered when
deciding whether a complaint should be dismissed and what to do when
disagreeing with a staff recommendation for dismissal.
• Board should enhance its medical consultant practices—The Board
should take several steps to strengthen its practices for using medical
consultants and staff doctors to review complaints. The Board uses both
staff doctors and medical consultants—licensed doctors who have
volunteered their services—to review complaints. However, auditors found
that board staff were inconsistent in explaining and applying board
practices for selecting staff doctors and medical consultants. One
underlying reason appears to be that many of these practices are not
formally reflected in board policies and procedures, and in some cases, the
practices themselves need to be enhanced. Issues needing further
1 The Board requested additional investigation for two complaints and later dismissed those complaints after additional
investigation was completed and the Board again reviewed the complaints. The Board issued an advisory letter for the
third complaint.
2 United States General Accounting Office (1999). Standards for internal control in the federal government [GAO/AIMD-
00-21.3.1]. Washington, DC: Author.
page 16
State of Arizona
attention include establishing guidance for selecting staff doctors and
medical consultants, requirements for ensuring that consultants review
training materials provided to them, and guidance for using consultants
again if limitations in their work result in the need to obtain a review from a
different consultant (see Finding 1, pages 7 through 12).
• Changes needed to address complaint-handling timeliness—The
Board should take various steps to ensure that it is processing complaints
in a timely manner. The Office of the Auditor General has found that Arizona
health regulatory boards should generally process complaints within 180
days. Auditors’ analysis showed that if the Executive Director does not
dismiss a complaint, it will likely take more than 180 days before it is
resolved (see textbox).
To ensure that it processes more complaints in a timely
manner, the Board needs additional information that will
allow it to determine not only overall timeliness, but also
the timeliness of key steps in the complaint-handling
process. The Board has a report that provides information
about investigation timeliness for each complaint, but the
report does not track other steps in the process, including
the final board action date or the date the Staff
Investigational Review Committee (SIRC) reviews the
complaint before forwarding the complaint to the
Executive Director for dismissal or to the Board for review
and/or final action. In addition, the report does not
include information on each complaint’s priority level.1
Board management reported that they thought the 180-
day standard applied only to the investigative phase.
However, because this standard applies to the entire
complaint-handling process, the Board should develop a
report to capture additional complaint-handling timeliness
information to help identify and address factors in the
process that may impact timeliness. Also, since it is important to handle
serious complaints in a timely manner to protect public safety, the Board
should include the priority level in its report so that it can assess whether
complaints are processed within required time frames according to
assigned priority.2 The Board may also need to modify its computer system
to include additional date fields. For example, the Board may need an
additional field to document the date the SIRC completes its complaint
review. Once the Board has developed a report, it should use this
1 Board policy requires staff investigators to assign complaint priority levels based on the allegations’ severity. Policy also
establishes time frames for completing investigations depending on the priority level.
2 Board management has a report that tracks complaint investigation timeliness according to severity level to ensure
timely investigations, but does not track the remaining parts of the complaint-handling process according to severity
level.
Complaint-Handling Timeliness1
Fiscal Year 2010
Executive director dismissals—650 complaints
• 91% processed within 180 days
• 9% processed within 181 days to 512 days
Board actions—197 complaints
• 24% processed within 180 days
• 26% processed within 181 days to 224 days
• 25% processed within 225 days to 279 days
• 24% processed within 280 to 617 days
1 This analysis does not include the 107 complaints where the
Board took other action, such as limiting a licensee's practice
during the investigation of a complaint (see footnote 3, page 4,
for additional information).
Source: Auditor General staff analysis of the Board’s complaint
data for 847 complaints investigated and resolved during
fiscal year 2010.
page 17
Office of the Auditor General
information to address factors within its control that cause delays in the
complaint-handling process.
• Board needs to improve two IT processes—Although the Board has
addressed information security weaknesses, it should improve its
information technology processes in two areas. According to board
management, the Board’s Web site was compromised in 2008. In
response, the Board obtained an external information technology security
assessment and addressed identified weaknesses. However, to ensure
that only appropriate individuals have access to confidential information,
the Board should follow a standard developed by the state Government
Information Technology Agency (GITA) that calls for classifying data and
developing a plan to secure data based on its classification. For example,
the Board receives patient records during complaint investigations and
licensee social security numbers on license application forms. Due to the
sensitive nature of this information, it is important that only those needing
the information to perform their job functions have access to it. The GITA
standard is intended to ensure that such data is protected within IT
systems.
In addition, to ensure continuous information technology services, the
Board should enhance its business continuity plan to address all the issues
included in the GITA standard for such plans. The Board retains complaint
investigation and license application information only electronically, so it
does not have a way to recover the data in the event of a system failure;
therefore, its ability to ensure continuity in its operations is compromised.
The Board needs to ensure that the information will not be lost and can still
be accessed should the Board’s information technology systems shut
down.
3. The extent to which the Board has operated within the public interest.
The Board has generally operated within the public interest, including:
• Web site provides extensive information and services—The Board has
a Web site that provides information to the public on licensees and board
activities. The Web site includes information on choosing a doctor, including
a specific guide to selecting a cosmetic surgeon, and information about
licensed doctors such as their education and training, and past disciplinary
information. The Web site also provides information about how to file a
complaint, the complaint-handling process, scheduled public meetings,
upcoming meeting agendas, and meeting minutes. For licensees, the
Board’s Web site provides access to application forms and allows licensees
to renew their application on-line.
page 18
State of Arizona
• Complainants’ anonymity protected—The Board is complying with
statutory requirements to protect the identities of anonymous complainants.
Specifically, board management reported that as of April 2010, the Board
began providing copies of complaints where the complainant requests
anonymity to licensees with any identifying information redacted. A.R.S.
§32-1451(G) requires that the Board not disclose the name of any person
who files a complaint if that person requests anonymity. Prior to April 2010,
according to board staff, it sent a summary of any complaints to licensees
where the complainant requested anonymity, and it may still send a
summary if the original complaint contains an abundance of information
identifying the complainant. However, board staff indicated that this rarely
occurs.
Auditors did identify one way in which the Board's procedures could be changed
to help it operate more effectively in the public interest:
• Board needs to provide additional public information on its Web site—
Statute requires the Board to provide the public with information on
licensees in response to a written request for information and on its Web
site. Auditors found that the Board’s procedures for responding to written
requests are consistent with statute. Further, auditors placed four phone
calls to the Board between August 23, 2010 and September 8, 2010, and
found that board staff provided information about the status of a doctor’s
license, the doctor’s education and training, and any disciplinary and
nondisciplinary actions taken against the doctor. However, auditors’ review
of the Board’s Web site found it did not meet the statutory requirement for
providing licensee information related to malpractice or felony and
misdemeanor charges and convictions for the past 5 years. To address this
issue, the Board sought changes to its statutes. Laws 2011, Ch. 227, limits
the Board’s requirements to provide information about misdemeanors and
malpractice actions to those resulting in board disciplinary actions.
However, the law still requires that licensees notify the Board of all felony
convictions and that the Board immediately update its Web site upon
receiving this information. Laws 2011, Ch. 227, will go into effect in July
2011. The Board should ensure that it obtains required information from
licensees and updates its Web site as required by statute.
4. The extent to which rules adopted by the Board are consistent with the
legislative mandate.
General Counsel for the Auditor General has reviewed an analysis of the Board’s
rule-making statutes by the Governor’s Regulatory Review Council staff,
performed at auditors’ request, and believes that the Board has fully established
rules required by statute.
page 19
Office of the Auditor General
5. The extent to which the Board has encouraged input from the public before
adopting its rules and the extent to which it has informed the public as to
its actions and their expected impact on the public.
The Board informs the public of proposed rules through Notices of Proposed
Rule Making filed with the Secretary of State’s Office and published in the
Arizona Administrative Record. For example, in July 2008, the Board filed a
Notice of Proposed Rule Making for changes it was making to its application
and licensing fee rules. The Board also obtains input from professional
associations and other stakeholders during the process of drafting rules and
incorporates their feedback into its rules.
In addition to involving the public in the rule-making process, the audit also
found that the Board involved the public in the process of revising its Pain
Management Guidelines in 2006. These guidelines constitute the Board’s policy
for the treatment of chronic pain by doctors. Specifically, the Board held a public
meeting in March 2006 to solicit feedback on the proposed adoption of the
Federation of State Medical Board’s model pain management guidelines and
other pain management guidelines. Board documentation indicates that the
Board incorporated feedback received from the public and stakeholders into its
guidelines. The guidance was revised in an effort to encourage doctors to
administer controlled substances in the course of treating pain without fear of
disciplinary action from the Arizona Medical Board.
As required by open meeting law, the Board has posted meeting notices and
board meeting agendas on its Web site at least 24 hours in advance and has
provided meeting minutes within 3 working days after the meeting. In addition,
the Board has posted a statement on its Web site stating where all its public
meeting notices will be posted.
6. The extent to which the Board has been able to investigate and resolve
complaints that are within its jurisdiction.
The Board has sufficient statutory authority to investigate and adjudicate
complaints within its jurisdiction and has various nondisciplinary and disciplinary
options available to use. However, as indicated in Sunset Factor 2 (see pages
16 and 17), the Board has not processed all complaints in a timely manner and
should take steps to ensure that it processes complaints in a more timely
manner, including developing a report to capture additional complaint-handling
timeliness information.
page 20
State of Arizona
7. The extent to which the Attorney General or any other applicable agency
of state government has the authority to prosecute actions under the
enabling legislation.
A.R.S. §41-192 authorizes the Attorney General’s Office to prosecute actions
and represent the Board. Board management reported that the Board retains
two full-time Assistant Attorneys General as legal representatives. One acts as
the Board’s legal representative during board meetings and general counsel in
day-to-day matters that come before the Board. The other represents the Board
for cases that go to formal hearings.
8. The extent to which the Board has addressed deficiencies in its enabling
statutes, which prevent it from fulfilling its statutory mandate.
The Board has sought statutory changes to address deficiencies in its statutes.
Specifically:
• In 2006, A.R.S. §32-1451 was amended to allow the Board to issue
nondisciplinary orders for continuing medical education (CME). Previously,
a board requirement to obtain CME was considered a disciplinary action.
According to board management, this resulted in reporting the action to the
National Practioner’s Database and increased malpractice fees for some
doctors. However, 2007 statutory amendments gave the Board more
flexibility regarding the type of CME the Board could require and clarified
that a CME requirement could be disciplinary or nondisciplinary.
• In 2011, various board statutes were revised by Laws 2011, Ch. 227. For
example, the Legislature amended A.R.S. §32-1401 to allow doctors to
write prescriptions or issue prescription medications to a member of a
patient’s household without first conducting a physical examination or
establishing a doctor-patient relationship with the household member if the
prescription or medication is for an immunization or vaccine. In addition,
changes to A.R.S. §32-1401.03 modified the Board’s responsibility to post
on its Web site (or provide in writing when requested) felony, misdemeanor,
and malpractice information about licensees (see Sunset Factor 3, page
18).
Additionally, Laws 2011, Ch. 227, eliminated a board requirement to
provide nondisciplinary information on its Web site. This brought the
Board’s statutes into alignment with A.R.S. §32-3214, which prohibits
health profession regulatory boards from providing nondisciplinary
information on Web sites on or before January 1, 2012. According to board
management, the Board is working to modify its computer system, which
is used to populate information on its Web site, to ensure the Board is in
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Office of the Auditor General
compliance with the new requirement. The Board anticipates the changes
will be completed by the end of calendar year 2011.
• Also in 2011, the Legislature passed Laws 2011, Ch. 97, which modified
A.R.S. §32-2842 by aligning state requirements for doctors who interpret
mammographic images with federal requirements. Specifically, this statutory
change will now require licensed doctors who interpret mammograms to
meet the federal education and training requirements for doing so.
The Board also reported that it has frequently sought to address deficiencies in
its statutes and taken action through the use of substantive policy statements to
reinforce stakeholder awareness and understanding of the statutes. For
example, in June 2008, the Board adopted the Duties of Hospitals and
Physicians to Report Peer Review/Quality Assurance Information Substantive
Policy Statement, which clarifies the statutory duties of hospitals and doctors to
promptly report unprofessional conduct among doctors.
9. The extent to which changes are necessary in the laws of the Board to
adequately comply with the factors in the sunset law.
The audit did not identify any needed changes to board statutes.
10. The extent to which the termination of the Board would significantly harm
the public’s health, safety, or welfare.
Terminating the Board and its regulation of doctors would significantly endanger
the public health, safety, and welfare if this regulatory responsibility were not
transferred to another entity. Auditors reviewed complaints the Board handled
that posed a threat to the public’s health, safety, and welfare, including practice
below the standard of care, substance abuse issues, and sexual misconduct.
Without a regulatory licensing function of allopathic doctors in Arizona, there is
less assurance that unqualified or incompetent doctors are excluded from
practice. In addition, without a regulatory complaint investigation and adjudication
function, there are fewer mechanisms to discipline doctors who cause harm.
Finally, without regulation, consumers would not have a source of information
about Arizona doctors’ qualifications and their complaint and disciplinary
history.
page 22
State of Arizona
11. The extent to which the level of regulation exercised by the Board is
appropriate and whether less or more stringent levels of regulation would
be appropriate.
The audit found that the current level of regulation the Board exercises is
appropriate.
12. The extent to which the Board has used private contractors in the
performance of its duties and how effective use of private contractors
could be accomplished.
The Board has entered into contracts and agreements and used
intergovernmental service agreements to perform activities beyond its staff
resources and abilities. For example, the Board uses medical consultants to
review complaints. Also, it contracts for some information technology services
to provide technical support for its licensing and complaint-handling software.
Additionally, as authorized by statute, the Board contracts with a third-party
group to administer its Monitored Aftercare and Physician Health Programs.
These integrated programs provide for the confidential treatment and
rehabilitation of doctors who are impaired by alcohol or drug abuse, or who
have medical, psychiatric, psychological or behavioral health disorders that may
impact a licensee’s ability to safely practice medicine or perform healthcare
tasks. According to board staff, there are usually an estimated 100 licensees
enrolled and participating in the integrated programs. As of April 15, 2011, there
were 99 licensees participating.
This audit did not identify any additional opportunities for the Board to contract
for services.
Office of the Auditor General
Methodology
This appendix provides
information on the methods
auditors used to meet the
audit objectives.
This performance audit was
conducted in accordance
with generally accepted
government auditing
standards. Those
standards require that we
plan and perform the audit
to obtain sufficient,
appropriate evidence to
provide a reasonable basis
for our findings and
conclusions based on our
audit objectives. We
believe that the evidence
obtained provides a
reasonable basis for our
findings and conclusions
based on our audit
objectives.
The Auditor General and
staff express appreciation
to the members of the
Arizona Medical Board and
its Executive Director and
staff for their cooperation
and assistance throughout
the audit.
Auditors used the following specific methods to meet its audit objectives:
• To determine whether the Board’s processes and practices helped
ensure appropriate complaint handling, auditors interviewed board
members, management, and staff; reviewed policies, procedures, and
statutes; analyzed information from calendar year 2010’s regular
board meeting minutes; and obtained computerized information
system data for complaints dismissed or sanctioned during fiscal year
2010, including dates for when the Board’s investigation began and
when the complaint was resolved. In addition, auditors reviewed a total
of 22 complaints that were completed between August 2009 and
February 2011. Seventeen of these 22 complaints were selected to
review and assess the Board’s entire complaint-handling process,
including the medical consultant selection and review processes.
These 17 complaints, which included 10 in which a consultant had
been used, consisted of the following:
° Five randomly selected complaints resulting in advisory letters,
which are nondisciplinary.
° Five randomly selected complaints resulting in less severe
disciplinary action, such as a letter of reprimand and probation.
° Five judgmentally selected complaints dismissed by the Executive
Director where the complainant asked the Board to review the
decision.
° The two most recent complaints from the time period reviewed
resulting in revocation.
Auditors reviewed another five complaints in addition to the 17
included in the sample. These five involved allegations regarding the
appropriate prescribing of pain management medications and were
examined solely to assess consultant selection. The five pain
management complaints were identified by board staff because the
Board’s computer system could not be queried for this information,
and were reviewed in response to concerns provided by the profession
and Legislature regarding how the Board handles pain management
complaints.
page a-i
APPENDIX A
page a-ii
State of Arizona
• Auditors’ work on internal controls focused on the Board’s policies, procedures,
and practices established for the complaint-handling process including those
related to timely processing of complaints. Information system data was used
to determine complaint-handling timeliness, so auditors conducted data
validation test work to ensure that the system information auditors used was
sufficiently complete and accurate for the purpose of determining complaint-handling
timeliness. Auditors interviewed staff who use the data, observed data
entry procedures, and identified some specific controls over data accuracy and
reliability. Also, auditors ensured that 17 complaints listed in board meeting
minutes were contained in the computer system and that dates contained in the
computer system for these same 17 complaints matched meeting minutes. In
addition, board data was used to determine license-issuing timeliness, so
auditors also conducted data validation test work to ensure that licensing data
was reasonably complete and accurate. Specifically, auditors verified board
license application timeliness report information against 10 randomly selected
licensee’s files to ensure accuracy. Also, to assess completeness, auditors
randomly selected 20 licensee files from an April 2011 board computer system
report and ensured that information from those 20 files was contained on the
Board’s license application timeliness report. In general, auditors concluded
that the Board’s complaint handling and licensing data was sufficiently reliable
for audit purposes.
• Auditors also used some additional methods to obtain information used
throughout the report, including the Introduction section and Sunset Factors.
Specifically, auditors observed three board meetings held on June 9 and 30,
2010, and October 14, 2010. In addition, auditors compiled unaudited
information from the Arizona Financial Information System (AFIS) Accounting
Event Transaction File for fiscal years 2008 through 2010 and the AFIS
Management Information System Status of General Ledger—Trial Balance
screen for fiscal years 2009 and 2010, and board estimates for fiscal year 2011
as of May 2011; placed four anonymous public information request phone calls
to board staff between August 23, 2010 and September 8, 2010; and reviewed
an analysis of the Board’s administrative rules performed by the Governor’s
Regulatory Review Council staff and a board notice of proposed rulemaking
filed with the Secretary of State’s Office.
AGENCY RESPONSE
Janice K. Brewer
Governor
Douglas D. Lee, M.D.
Arizona Medical Board Chair
9545 E. Doubletree Ranch Road • Scottsdale, AZ 85258-5514
Telephone: 480- 551-2700 • Toll Free: 877-255-2212 • Fax: 480-551-2704
Website: www.azmd.gov
Lisa S. Wynn, B.S.
Executive Director
June 14, 2011
Debra K. Davenport, CPA
Auditor General
Office of Auditor General
State of Arizona
2910 N. 44th Street, Ste. 410
Phoenix, AZ 85018
Dear Ms. Davenport,
On behalf of the Arizona Medical Board, I have submitted the agency’s response to the Audit Report
conducted by your office.
The Arizona Medical Board and its staff sincerely appreciate the time and resources committed by the
audit team to understand the complex nature of the procedures used to balance preserving the due
process rights of licensees without compromising our core function of protecting the public.
I would also like to take this opportunity to recognize the professionalism of your staff throughout the
audit process. The recommendations identified in the report, which have either been implemented or
are in the process of being implemented, will allow the agency to continue in its ongoing commitment to
excellence in the regulatory oversight of health professionals under the jurisdiction of the board.
Thank you, again, for your consideration.
Respectfully,
Lisa S. Wynn
cc: Arizona Medical Board Members
Final Audit Response
Arizona Medical Board
June 14, 2011
Finding 1: The Board should improve staff doctor and medical consultant selection, and medical
consultant training and problem resolution practices.
The Board and its staff recognize the critical role played by staff doctors and medical consultants who
conduct clinical reviews of cases. In response to this audit, the Board has developed written policies to
enhance the quality of our pool of medical consultant volunteers, improve our process for selecting
consultants for each case, and ensure that consultants receive adequate training,
Recommendations:
1.1 The Board should formalize its staff doctor and medical consultant selection practices in written
policies and procedures, including how board staff should consider the nature of the complaint
and licensees’ practice specialties in determining the selection of consultants.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.2 The Board should establish and implement policies and procedures regarding medical
consultant qualifications, and complaint review time frames and requirements.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.3 The Board should establish and implement a process for requiring and ensuring that its medical
consultants complete board-provided training before they review complaints. One way to do
this would be to request confirmation from the consultants that they had reviewed the training
materials.
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Implementation will be complete by August 2011. The Board was recognized by the Federation of State
Medical Boards in 2011 in its national bi-weekly publication for its best practice of on-line medical
consultant training. In April 2010, Administrators in Medicine (AIM), a national association of medical
board administrators, recognized the Board for its Outside Medical Consultant Recruitment and
Education efforts as a Best of Boards honorable mention recipient.
1.4 The Board should establish and implement written policies and procedures that provide
guidance on when medical consultants should not be used or should be used only for certain
types of complaints.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented.
1.5 The Board should establish and implement policies and procedures on how and where problems
with specific medical consultants’ work and decisions regarding the continuing use of these consultants
should be documented.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. This information is being entered into our data system on the profile of the consultant.
We are utilizing a comments field to document if a consultant should not be utilized, or should be
utilized only in certain types of cases, and why.
Sunset Factors
• Executive Director complaint dismissals appear appropriate, but additional guidance should be
established in policy.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. The Board has established a policy that identifies the steps its Executive Director takes
when deciding whether to dismiss a complaint. The policy includes the steps taken when the Executive
Director denies a staff recommendation for dismissal and sends the case for further investigation.
• Changes are needed to address complaint-handling timeliness.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. The Board has strived to maintain excellent response time, both in the issuance of
licenses and the completion of complaint investigations. A portion of the complaint resolution
timeframe is dependent on the provision of due process for the physician. Once a case has been
referred to Formal Hearing, the Office of the Attorney General becomes responsible for preparing and
scheduling it for hearing pursuant to timeframes established in A.R.S. § 41.1092.05. The Board has
revised internal reports that track the timeliness of the handling of the complaint, including the priority
level and post-investigation timeframes.
• Board needs to improve two IT processes.
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Board Chief Information Officer developed the Board’s first IT Strategic Plan in 2010, and has
continually updated it as needs are prioritized and resources become available. Both processes
identified here are on the current IT Strategic Plan (Data Loss Prevention/Identity and Access
Management/Disaster Recovery) with Disaster Recovery projected to be completed by June 30, 2011
and the others projected to be completed in FY2012. The Board has significantly improved the security
posture of the agency and in May 2011 was recognized by the International Data Group’s
Computerworld Honors Program as a 2011 Laureate for the Board’s Security Awareness initiatives.
• Board needs to provide additional public information on its Web site.
The finding of the Auditor General is agreed to and the audit recommendation has been
implemented. It would be extremely unusual for a physician to have a felony conviction and not have
either a permanent or interim action on the physician profile as a result, but we have changed our policy
and process to ensure that all felony convictions are posted as soon as they are reported.
Future Performance Audit Division reports
Pinal County Transportation Excise Tax
Performance Audit Division reports issued within the last 24 months
10-04 Department of Agriculture—
Food Safety and Quality
Assurance Inspection Programs
10-05 Arizona Department of Housing
10-06 Board of Chiropractic Examiners
10-07 Arizona Department of
Agriculture—Sunset Factors
10-08 Department of Corrections—
Prison Population Growth
10-L1 Office of Pest Management—
Regulation
10-09 Arizona Sports and Tourism
Authority
11-01 Department of Public Safety—
Followup on Specific
Recomendations from Previous
Audits and Sunset Factors
11-02 Arizona State Board of Nursing
11-03 Arizona Department of Veterans’
Services—Fiduciary Program
09-06 Gila County Transportation
Excise Tax
09-07 Department of Health Services,
Division of Behavioral Health
Services—Substance Abuse
Treatment Programs
09-08 Arizona Department of Liquor
Licenses and Control
09-09 Arizona Department of Juvenile
Corrections—Suicide Prevention
and Violence and Abuse
Reduction Efforts
09-10 Arizona Department of Juvenile
Corrections—Sunset Factors
09-11 Department of Health Services—
Sunset Factors
10-01 Office of Pest Management—
Restructuring
10-02 Department of Public Safety—
Photo Enforcement Program
10-03 Arizona State Lottery
Commission and Arizona State
Lottery